Document of

The World Bank

FOR OFFICIAL USE ONLY

Report No. 5440-MOR

STAFF APPRAISAL REPORT

KINGDOM OF MOROCCO

HEALTH DEVELOPMENT PROJECT

May 15, 1985

Population, Health and Nutrition Department

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

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CURRENCY EQUIVALENTS

US$1.00 = Dirham (DH) 9.47DR 1.00 = US$0.106

FISCAL YEAR

January 1 - December 31

MOROCCO FORI OMFCIAL USE ONLY

HEALTH PROJECT

Table of Contents

Page No.

Table of Contents .............................. iLoan and Project Summary -*............................. ivBasic Data Sheet ........... ..... ...... ..... .. ........ viDefinitions ........... ...... 0...................... viiAbbreviations ......... .........................*..* ** ix

I. THE SECTOR . ............................. 1Background ........................................... 1

A. Population .............................. 1Population Profile ........... ................... 1Population Policy ............................ 0.... 2

* Family Planning Program ............................. 3

B. Nutrition ...................................... 4Nutritional Status .............................. 4Causes of Malnutrition .............................. 5Government Nutrition Policies rnd Programs .......... 6

C. Health .................................................. 6Health Status ............................................. 6Environment ............................ ............. 8Bealth Services and Programs ........................ 9Government Health Policy ............................ 10Public Health Services . ..................... ........ 11

D. Sectoral Resources ............... ...................... 12Physical Resources .................... .. . ................ 12Human Resources ..................................... 13Financial Resources .. ............................... 14

E. Sectoral Issues ........................................ 15Health Care Delivery System ......................... 15Management ........................................... 16Supply of Basic Drugs ............. . ....................... . 16

F. Summarv Assessment of the Sector ....................... 18

G. Government's Objectives and Bank Role .................. 19

This report is based on the findings of an appraisal mission vhichvisited Morocco in September/October 1984. The mission consisted ofMessrs. Jean Pillet (Mission Leader), Louis G. Vassiliou, Richard Skolaik,Bernard Hubert, and Ms. Taraneh Tavana, World Bank staff, and Messrs. HankSchut and Jean Lecoute, World Bank consultants.

This document has a restricted distribution and may be ued by recipients ooiy in the performance oftheir offcl duties Its contents may not otherwise be disdosed without World lank authorization.

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II. THE PROJECT .. **................................. .. 20

A. Proiect Concept and Obiectives .............. ............ 20

B. Project Composition ..................................... 20

C. Proiect Description ... .................................... 21* Primary Health Services Component ..... ............... 21

Management Component ....... .......................... 23* Training and IEC Component ........................... 25. Supply of Basic Drugs ...... ....................... 27

III. PROJECT COSTS AND FINANCING .......................... 30* Cost of the Project ......... ..... .... 30. Project Financing ... ....... .......................... 32

IV. PROJECT ORGANIZATION AND IMPLEMENTATION ............... 33Organization .. . .......................... 33

. Procurement ..................... ...................... 34= Disbursement ......................................... 35* Accounts and Audits .................................. 36. Monitoring ................. ............ ....... 37

. Reporting and Evaluation ............. ............... 38

V. PROJECT JUSTIFICATION AND RISKS .......................... 39Justification ........................................ 39

. Risks .... ............................................. 40

VI. AGREEMENTS AND RECOMMENDATIONS .................. ..... 41= Condition of Board Presentation .......... .. .......... 42. Conditions of Disbursement ........... ................ 42

ANNEXES

ANNEX A - Morocco Health Sector Basic DataTables A.1 Contraceptive Prevalence .. ................ 44

A.2 Nutrition ........... ................... 45A.3 Causes of Mortality .. ..................... 46A.4 Profile of Demand for PHC .. ............... 47A.5 Manpower Resources .a ................... ... 48A.6 Manpower Education .................... .... 49A.7 Health Care Facilities ... ................. 51A.8 Capacity and Utilization of Hospitals ..... 52A.9 MOPE Operating and Capital Budget .. ....... 53A.10 Foreign Assistance in Population and

Health Activities ....... .................. 54

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ANNEX B - Proiect AreaDescription ................ 55Tables B.1 Socio-demographic Characteristics ......... 58

B.2 Population Distribution ................... 59B.3 Contraceptive Prevalence by Method ........ 60B.4 Family Planning Acceptors ....... .......... 61B.5 MCH Consultations . ........ .... ........... 62B.6 Existing Manpower . ............ * * * . * * * * * * .. 63B.7 Additional Manpower ....................... 64

ANNEX C - PHC Core Proprams ................... ........ ... 65

ANNEX D - PHC Strategies ............................ 71

ANNEX E - Organization of the Health Delivery System ........ 74

ANNEX F - Plannina and StudiesStructure and Rer.ponsibilities of the DICP ....... 75

ANNEX G - Druft Supply SystemOptions for the supply of basic drugs ............. 79

Tables G.1 Requirements and Supply of Basic Drugs .... 82G.2 Sequence of Operations of the Drug

Supply System . ........... ......... ...... 83

ANNEX H - Proiect ImplementationTables H.1 MOPH Organizational Chart ................ 84

H.2 Project Implementation OrganizationalChart ................... .................. 85

H.3 Project Implementation Timetable ......... . 861.4 Technical Assistance ............ .......... 87

ANNEX I - Disbursement & Cost Tables ................. ..... 88-96

ANNEX J - IBRD Allocation ...... ........................... 97

ANNEX K - Selected Documents and Data Available in theProject File ................................... 98-99

Maps IBRD 18651, 18652, 18653 ....................... ..... 100-102

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KINGDOM OF MOROCCO

HEALTH DEVELOPMENT PROJECT

Loan and Proiect Summary

Borrower The Kingdom uf Morocco

Beneficiary The Ministry of Public Health (MOPH)

Amount US$28.4 million equivalent

Terms Payable in 20 years, including fiveyears of grace at the Bank's standardvariable interest rate. The Borrowerwould bear the foreign exchange andinterest rate risks. The loan wouldinclude the refinancing of the PPFof about US$.08 million equivalent.

Project Description The project would assist the Ministryof Public Health in strengtheningand accelerating the ongoing shiftfrom an urban-based hospital-orientedhealth system to a more cost-effectivesystem of lrimary care includingfamily planning. The project wouldinclude: (a) the strengthening ofprimary care in three provinces byupgrading and expanding the physicalinfrastructure, provision of equipment,training of health staff and improvinglogistics; (b) the improvement ofMOPE management; (c) the strengtheningof training and IEC programs, and(d) the improvement of the supplyof basic drugs. The main benefitsof this first project in the healthsector are to provide the Governmentwith a cost-effective model for primarycare including family planning, whileraising the capacity of the centralMOPE to improve the logistics andyet control the costs of the healthcare delivery system. The main riskof the project relates to the stringencyof MOPH recurrent budget. This riskis being addressed by minimizingincremental operating costs whilereducing unit costs of the services.

Project Costs Estimates:(US$ million)

Local* Foreizn TotalA. Development of Basic

Health Services 12.5 10.7 23.2B. Strengthening of

NOPH Management 0.8 0.9 1.7C. Strengthening of Trainiug

and IEC Capacity 0.5 1.1 1.6D. Improvement of Drug

Supply System 2.4 4.4 6.8

Total Baseline Costs 16.2 17.1 33.3

Physical Contingencies 1.2 1.5 2.7Price Contingencies 4.9 4.6 9.5Provision for imple-mentation delays 1.0 1.1 2.1

Total Project Costs 23.3 24.3 47.6

(USS million)**Financing Plan: Local Foreian Total

IBRD 4.1 24.3 28.4Government 19.2* - 19.2Total 23.3 24.3 47.6

Estimated Disbursements:Bank Fiscal Year

1986 1987 19°8 1989 1990 1991 1992

Annual 1.3 3.7 5.4 6.0 6.0 4.5 1.5Cumulative 1.3 5.0 10.4 16.4 22.4 26.9 28.4

* Includes US$7.1 million equivalent in taxes.** This includes US$2.1 million provision for implementation delays.

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MOROCCO

HEALTH DEVELOPMENT PROJECT

Basic Data Sheet

A. General Country Data:

1. Area (km2) 447,000 19832. Total Population (Million) 21.4 19833. Population Projections (Million) 31.0 20004. GNP per Capita (US$) 870 19835. Urban Population as Percentage of Total 42 1983

B. PoDulation Data:

1. Rate of Population Growth (Z) 2.6 1970-822. Rate of Natural Increase (Z) 2.9 1970-823. Total Fertility Rate 5.8 19834. Total Fertility Rate:

- Among Women with No Schooling 6.4 1980- With Seven Years of Schooling or More 4.1 1980

5. Crude Birth Rate (per 1,000) 46.0 19826. Crude Death Rate (per 1,000) 13.5 19827. Infant Mortality Rate .(per 1,000) 120 19838. Percentage of Women of Childbearing

Age Using Contraception 25.5 19839. Dependency Ratio {X) 96 1982

C. Health Data:

1. Life Expectancy at Birth (Years) 56 19822. Infant Mortality Rate 98 19813. Child Death Rate 22 19824. Physicians per 1,000 Population 0.89 19825. Health Expenditures per Capita (US$) 8.35 19826. Hospital Beds per 1,000 Population 1.2 1983

E. Education Data:

1. Adult Literacy Rate 57 19822. Percentage of Age 14-49 Ever Enrolled

in Primary School:- Female 34 1980- Male 71 1980

3. Number Enrolled in Secondary Schoolas Percentage of Age Groups:

- Female 20 1981- Male 31 1981

4. Number Enrolled in Higher Education asPercentage of Population Aged 20-24 Years 6 1981

Sources: World Development Report, 1984; MOPH; Sample Survey of 1983Census Data.

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POPULATION. MM=LTH AND NUTRIUTION

DEFINITIONS

Adult Literacy Rate . The percentage of persons aged 15and over who can read and write.

Child Mortality Rate : Annual deaths of children 1-4 yearsper 1,000 children in the same agegroup.

Contraceptive Prevalence Rate The percentage of married women ofreproductive age who are using amodern method of contraception atany time.

Crude Birth Rate : Number of live births per year per1,000 people.

Crude Death Rate Number of deaths per year per 1,000people.

Degree of Malnutrition The Gomez classification scale distinguishesthree degrees in malnutrition, namely:first (mild) - 75-90 of expected

(or standard)weight forage

second (moderate) - 65-75X of expectedweight

third (severe) - under 60% ofexpected weightor sufferingfrom edema.

Dependency Ratio Population 14 years or under and65 years or over as percentage ofactive population (aged 15 to 64years).

Incidence Rate The number of persons contractinga disease as a proportion of thepopulation at risk, per unit of timeusually expressed per 1,000 personsper year.

Infant Mortality late Annual deaths of infants under 1year per 1,000 live births duringthe same year.

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Life Expectancy at Birth The number of years a newborn childwould live if subject to the age-specificmortality rates prevailing at timeof birth.

Low Birth Weight (LBW) Infant weight at birth less than2,500 gr. LBW may be associatedwith either pre-term (less than 37weeks gestation) or full-term butsmall-for-dates (38 weeks or more)of gestation.

Maternal Mortality Rate Number of maternal deaths per 1,000births in a given year attributableto pregnancy, childbirth or post-partum.

Morbidity The frequency of disease and illnessin a population.

Mortality The frequency of deaths in a population.

Neonatal Mortality Rate The number of deaths of infants under28 days of age in a given year per1,000 live births in that year.

Perinatal Mortality Rate The number of fetal deathJ after28 weeks of pregnancy and of infantdeaths under 7 days of age in a givenyear per 1,000 liv. b .ths.

Prevalence Rate The number of persons having a particulardisease at a given point in timeper population at risk; usually expressedper 1,000 persons per year.

Rate of Natural Increase Difference between crude birth andcrude death rates; usually expressedas a percentage.

Total Fertility Rate The average number of children awoman will have if she experiencesa given set of age-specific fertilityrates throughout her lifetime. Servesas an estimate of average numberof children per family-

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AIPF - Association Narocaine de Planification Familiale - MoroccanFamily Planning Association

ASS - Agent de Sant& Nrivet& - Auxiliary Nurse

ASDE - Agent de Sante Dipla8in d'Ktat - Certified Nurse

ASDES - Adjoint de Sant& Dipl8m6 d'ltat Spfecialiste - SpecializedNurse

CIDA - Canadian International Development Association

CNSS - Caise Nationale de la S6curite Sociale - Social SecurityFund

CP - Central Pharmacy

Du - Direction des Affaires Administrative* (MOPH) - Directorateof Administrative Affaizs

DAT - Direction des Affaires Techniques (MOPH) - Directorateof Technical Affairs

DICP ' Division de l'Infraatructure Charg&e de la Planification- Department of Infrastructure in charge of Planning

ENAP . Ecole Nationale d'Administration Publique - NationalCollege of Pub'lic Administration

FP - Family Planning

GDP - Gross Domestic Product

COM - Government of Morocco

IFC - Information, Education, Comunication

DIF - International Mo.aetary Fund

INI - Infant Mortality late

IPPF - International Planned Parenthood Federation

IPIIS - International Phar-maceutical Market Information System

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IUD 0 Intra-uterine Device

JRPIEGO - Johns Hopkins Programs of International Education inGynecology and Obstetrics

NCR - Maternal and Child Health

NoPE - Ministry of Public Health

MWRA * Married Women of Reproductive Age

ONEP - Office National de l'Eau Potable - National Office ofWater Supply

PDC a Points de Contact - Meeting Points

PHC - Primary Health Care

FEV - Programe d'Etat de Vaccination - State Vaccination Program

PIU - Project Implementation Unit

PSME - Protection de la Sante Maternelle et de l'Enfant - Maternaland Child Health

SIAhP - Service de l'Infrastructure d'Actions Ambulatoires Provinciales- Regional Office in charge of Ambulatory Services

TFR - Total Fertility Rate

fUl - Unite d'Approvisionneuent en Medicaments - Drug SupplyUnit

UNSF - Mobile Family Health Units

UNFPA - United Nations Fund for Population Activities

UNICEF - United Nations Children's Fund

USAID - United States Agency fcr International Development

VAD - Visite i Domicile - House V-1it

VDMS - Visite a Domicile de Motivation Systimatique - HouseVisit for Systemtic Motivation)

WHO - World Health Organization

I. THE SECTOR

Background

1.01 Morocco is situated in the northwestern corner of Africa.Forty-five percent of the population is concentrated in the coastalplains of the north and northwest which occupy only 15% of the totalcountry area. This region, with its fertile soil, good rainfall andnatural resources, contains most of Morocco's modern agriculture andindustry, and consequently enjoys a higher standard of living than therest of the country.

1.02 Morocco is going through a period of economic and financialdifficulties. The growth of real GDP has remained constant since 1979except for a slight increase in 1980. The budgetary deficit has increasedsharply, reaching 14% of GDP in 1983. The current account deficit hasincreased from US$124 million in 1970 to US$1.9 billion or 13% of GDPin 1983. The debt service ratio increased from 21% in 1979 and 27%in 1980 to 37% of the value of exports of goods and services in 1983.Efforts to improve the economic situation have been hampered by:a) the rise in oil prices from the mid-70s to 1980; b) the severe droughtof 1980-81; c) the increase in the debt service burden due to the appreci-ation of the US dollar and the rise in international interest rates;and d) a further decline in 1982 in the world market price of phosphate,Morocco's chief export.

1.03 Hence, in the years to come, the Government vill face twomajor challenges: a) the need to accelerate economic growth; b) theneed to improve the effectiveness of its social policies in reachingthe disadvantaged groups as well as the need to reduce unit costs of.public services provided to the population. The present project willhelp the Government achieve this second objective in the health sector.

A. Population

Population Profile

1.04 Morocco had a population of 21.4 million in 1984. The crudebirth rate remains high at 46 per 1,000, although the 1980 FertilitySurvey indicates a decline of the crude birth rate, at 41 per 1,000.The crude death rate has reached 13 per 1,000 in 1980, and the returnof migrants offsets the diminishing emigration. Preliminary resultsof the 1982 census reported a total population of 20.3 million, whichindicates a rate of natural increase of 2.9% over the last decade.The total fertility rate (TmR) is still high at 5.8. Morocco has ayoung population as a result of high fertility and a reductio ='- infantand child mortality. The proportion below 15 years of age rose steadilyto 42% in 1982, but is expected to decrease slightly in the next fewyears. The number of vomen of reproductive age rose from 4.4 millionin 1980 to 5.3 million in mid-1984. Since the number of women of repro-ductive age is bound to increase, even if fertility declines, the crudebirth rate is likely to remain high until the year 2000.

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1.05 Rapid population growth imposes a considerable burden on theeconomically active population. The dependency ratio has stabilizedat the very high figure of 96, as the slight decline in the lover agegroups is offset by the increase in the age group 65 and over. Inaddition to creating a need for more schools and houses, and ezertingpressure on food supplies, population growth is responsible for theincreasing drift of population from the countr3 to the towns, nowrunning at the rate of 300,000 a year.

1.06 In Morocco, fertility is highest among illiterate rural women.In 1982 the fertility rates for educated and illiterate women were 4.1and 6.4 respectively. In the same year, the fertility rates for urbanand rural women were 6.3 and 7.4 respectively. If present fertilitycontinues, the total population could reach 34.4 million by the year2000; a moderate decline in TFl - to 4.8 in the next five years -would still result in a population of 32 million. Only a rapid andsustained decline in TFR from present 5.8 to 2.6 could keep the popu-lation in the year 2000 below 30 million.

Ponulation Policy

1.07 As early as 1966, the GO showed its awareness of theimplications of rapid population growth by including a family planningprogram in the 1968-72 Development Plan. However, only in 1979 didMNOPH launch a large-scale family planning program. Although KingHassan II has reaffirmed the high priority of the population problem,the Government has not adopted explicit demographic objectives. The1981-85 Development Plan does not set population targets for any specificyear; it does, however, call for a slower demographic growth and setsa target of 24% of contraceptive prevalence for 1985 - which wouldhave resulted in a 23.5 million population in 1985 and eventually 36.9million in the year 2000. Contraceptive prevalence, however, increasedrapidly and by mid-1983 it surpassed the target 'And reached 25.5%(Annex A.1). Encouraged by this progress the Government envisages settinga 33% contraceptive prevalence target for 1990 in the next plan. Assumingthat subsequent five-year plans vould continue to raise contraceptivetargets, the country"s population could be limited to 30 million bythe year 2000. Within the Government, MOPH has full responsibilityfor expanding family planning activities, vhile the Ministry of Planningis responsible for the coordination of policies. Some sectors have,so far, provided lukewarm support to population activities: populationeducation in primary and secondary schools or in the Ministry of Youthand Sports programs has remained insufficient; low coverage of socialsecurity programs, particularly health and retirement insurance, stillacts as an incentive for large families; the legal status of women,especially the customary legislation on the age of marriage, polygamyand repudiation, remains a drawback for family planning. The 1986-88Development Plan should strengthen other sectors' support to populationand should introduce some of the desirable changes in social policiesand legislation.

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Family Plannins Program

1.08 The Government has maintained a policy of integrating familyplanning and health programs. IOPH has placed its Population and NCIDivisions under a single Directorate of Technical Affairs (DAT). DATexecutive.i have been the pioneers and are the most active promotersof family planning in the country; they have successfully mobilizedresources and staff into an integrated MCR/FP program.

1.09 MOPE has clear family planning objectives: birth spacingthrough .reast-feeding and contraception by modern methods - especiallycondoms, pills, IUDs and tubal ligations. Priority target groups aremultiparous w.,men, teenagers, and women over 35 years. MOPE distributescontraceptives through all its 1,426 outpatient facilities. Familyplanning clinics are held in all dispensaries, health centers and outpatientdepartments of hospitals. In addition to external funding, governmentexpenditures on family planning in 1983 reached US$6.9 million - US$1.5per woman of reproductive age. In spite of these efforts, the nationalprogram does not reach the entire population, many of whom live in inaccessibleareas. With a view to increasing coverage, in 1979 NOPE initiated,with support from USAID and UNFPA, a pilot outreach project known asVisites a Domicile de Motivation Systemtique (VDNS). Under this program,paramedical personnel make five annual visits to every household witha woman of reproductive age to give family planning information or adviceand to supply contraceptives, or direct women to Reference Centers orMobile Units for I1ID insertion or tubal ligation. After a successfultest in the Province of Marrakech, the VDNS system was extended to threemore provinces and expanded to include health education, the distributionof oral rehydration salts, iron tablets and nutrition supplements andreferral for immunization, which proved effective and well-accepted.A 1983 USAID evaluation of the program showed that contraceptive prevalencehad risen from 24% to 41% in Meknes and 52Z in Marrakech, compared withthe national average of 25.5%. According to the USAID report, the experiencehas demonstrated that: a) family planning, hone visits and contraceptivedistribution by male and female health workers are well-accepted inMorocco; b) the provision of family services through the existing healthservices is the best vay of ensuring long-term-availability and coverage;and c) an efficient family planning program can be conducted in theabsence of high visibility policy statements. MOPE will extend theprogram to the rest of the country. Over the next five years, the fivelargest urban areas and 16 provinces will be given priority, 13 provinceswould be financed by USAID and three by the Health Development Project.

1.10 Family planning progra are supported by Information/Education/Coimunication (IEC) activities. The Health Education Unit in MOPH'sPopulation Division is responsible for the production of IEC materialsfor FP and PEC, but because it is also expected to meet the printingneeds of the whole MOPH, it is overtaxed and finds it difficult to perform

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its primary function adequately. As a result, manuals and handoutson family planning and NCR are insufficient and unattractive; IEC messagesfor family planning - posters, pamphlets, audiotapes, TV and radiospots - are often too theoretical. MOPH has 22 large IEC tractor-trailers,fully equipped for exhibits and projections of 16 and 32 films, butthey are restricted to the main roads. They have proved useful forurban and suburban populations but bad only a limited impact in ruralareas.

1.11 Other Ministries and government agencies, such as Education,Social Affairs, Agriculture, Youth and Sports, are increasingly supportingthe population program, and the Ministry of Planning is coordinatingtheir activities. A private body, the Association Marocaine de Plani-fication Familiale (AMPF), supported by the International Planned ParenthoodFederation (IPPF), operates family planning centers and programs forthe distribution of contraceptives, trains private physicians in contraceptivemethods, produces and disseminates IEC materials. USAID, the main foreigncontributor to family planning, provides US$3.6 million per year onaverage. UNFPA has provided a total of US$8.7 million over the lastten years. These funds have been used to provide technical assistance,infrastructure, equipment and vehicles, training, demographic studiesand a National Household Survey. In addition to UNFPA, UNDP, UNICEF,WHO and USAID-supported Johns Hopkins Programs of International Educationin gynecology and obstetrics (JHPIEGO) have provided technical assistanceand training, as well as support for MOPH's Center for Human Reproductionin Rabat, which conducts national and international training programsin tubal ligation for physicians.

B. Nutrition

Nutritional Status

1.12 The Moroccan rural population in general is poorly nourished.The last nutrition survey, conducted in 1971, revealed that 42% of childrenunder four years of age suff'-!..d from moderate protein-calorie malnutrition,5% from severe malnutrition and 23% suffered from rickets. Forty-fivepercent of rural children under four years of age suffered from moderateand 6X from severe malnutrition. Although the average birth weight andheight of Moroccan newborn children exceed normal standards, a seriousdeterioration takes place between 10 and 48 months. For example, at 24months of age, the average height and weight of children are 7.3 cm and2 kg respectively below normal. This deterioration is due to abruptweaning, undernutrition and unsanitary conditions. Among the adultpopulation, pregnant and lactating women on the average have a calorieintake 12% below the desirable minimum, and suffer from iron deficiencyanemia, which is aggravated by successive pregnancies and short intervalsbetween births.

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1.13 The nutritional status markedly improved in the aid-seventieswhen food production was abundant. At the same time rickets was virtuallyeradicated througn a large-scale NCR program and administration of long-actinginjectable Vitamin D. There is reason to believe that the nutritionalstatus has deteriorated since 1980; the analysis of the 1983 NationalSurvey on Housebold Expenditure data and a survey of the nutrition ofchildren under four years of age planned to begin early in 1985 willprovide up-to-date information on the nutritional status of the population.

Causes of Malnutrition

1.14 The most important causes of malnutrition are inadequate foodproduction and consumption, bad infant feeding practices and poor environ-mental hygiene:

(a) Food Production Patterns. The decline in agricultural productionsince the 1970s caused by variations in rainfall and the recentdrought has contributed to the poor nutritional status ofthe population. Before 1970, Morocco produced enough cerealsto meet its domestic needs. However, the rate of growth ofagricultural outrut had fallen drastically from 4.7% in the1960s to -0.3% by 1979. This failure of food production tokeep pace with population has created food shortages and increaseddependence on imports. In the high Atlas mountain rangesand semi-desert areas of the South, protein-calorie malnutritionas well as vitamin deficiencies are due to seasonal food shortages.

(b) Food Consumption Patterns. The 1971 Nutrition Survey showedthat the average calorie and protein intake of Moroccans isgood. However, the typical diet is unbalanced and low inanimal protein and fats. The intake of nutrients varies considerablyfrom one income group and from one geographical region toanother. In urban areas, the calorie intake of affluent groupsaverages 110% of requirements, compared with 75Z in shantytowns. In "he rural areas of the South, the average calorieintake is 81% of requirements. Protein-calorie malnutritionis severe among low-income groups (DE 466 and below), farmworkers, self-employed, artisans, and unemployed. The calorieintake of this group ranges from 61S to 66% of requirements.

(c) Infant Feeding Practices. The decline in breast-feeding inrecent years may endanger the nutrition and health of youngchildren. During weaning, breast milk or infant formulasare supplemented by vheat or barley only, causing proteindeficiency around 14 months WQen weaning is completed.-

(d) Environmental Sanitation. The nutritional value of food isoften reduced by improper preparation. Contaminated foodand water are prime causes of infant diarrhea, in turn animportant contributing factor to malnutrition.

Government Nutrition Policies and Programs

1.15 In spite of the GOM's recognition of the critical need toimprove nutrition, Morocco has no intersectoral food and nutrition policy.MOPH is responsible for crinical services and nutrition education whilean interministerial committee under the Ministry of Planning was expectedto coordinate food and nutrition policies, but has remained inactive.To follow up on a food strategy study, carried out by the Governmentwith CIDA assistance, an intersectoral task force, under the Ministryof Agriculture, has completed by June 1984, a first phase of analysisand is presently developing alternatives for a food strategy.

1.16 Within its limited responsibilities MOPH has addressed theproblem of malnutrition in the following ways:

(a) Nutrition education and IEC tbrough mass media, mobile units,VDHS and clinics. The effect_veness of such interventionsbas not been evaluated.

(b) Nutrition surveillance through clinical screening of infants,pregnant and lactating vomen. However, in 1979 the programreached only IOZ of children in the 0 to 2 age group.

(c) Nutrition rehabilitation through distribution of Actamin,a protein-rich weaning flour, in MCR clinics. Actamin isalso-sold at a subsidized price in pharmacies. The productionand distribution of Actamin have proved costly, and MOPE isseeking suitable alternatives.

1.17 MOPH programs for combating malnutrition are well-conceivedbut require better definition and targeting. Active rather than passivedetection would increase coverage. Coordination with immunizationsand oral rehydration techniques would increase the efficiency of theprogram.

1.18 The Ministry of Social Affairs also conducts nutrition educationand food distribution programs, the Ministry of Education provides nutritioneducation in schools, and the Ministry of Agriculture promotes foodcrop and home gardening. Hovever, there is little effective coordinationof the efforts of these other ministries with those of MOPE.

C. Health

Health Status

1.19 In spite of its low per capita income, Morocco, like its neighbors,Algeria and Tunisia, exhibits a steady decline of infectious and parasiticdiseases. The deatb rate, which fell from 17.5 per 1,000 in 1970 to

13.5 in 1980, is estimated at 12 per 1,000 in 1984. Life ezpectancyrose steadily from 50 years in 1970 to 56 in 1980. The high infantmortality, more than 100 per 1,000, and the prevalence of malnutritionand tuberculosis indicate, hovever, that these favorable trends mayhave slowed dow.

1.20 Moroccan health statistics are incomplete, and the basichealth data necessary for planning are insufficient. Births are grosslyunderreported or reported late, and death certificates do not requirerecording the cause of death. To supplement the inadequate data base,MOPE has relied on specific studies; however, the more comprebensiveand therefore more useful indicators, such as age-specific mortality,infant, child and maternal mortality, and causes of morbidity, are notavailable. Statistics on mortality by causes and age groups are basedon deaths in hospitals - only 13% of total deaths -- and satisfactorydeath certificates, which account for only 1.5% of total deaths, arethus not representative of the entire population.

1.21 Mortality. MOPE officially reported the Infant MortalityRate (IMR) at 91 per 1,000 live births in 1981. However, realisticestimates put it at 120 per 1,000. Deaths in the first year of lifeaccount for 43Z of total mortality. Studies on infant mortality reveala disparity between income groups; in the modern urban sectors, infantmortality is estimated at 60 per 1,000, but it reaches 170 per 1,000in the periurban shanty towns. Infant mortality in rural areas rangesfrom 110 in the plains to 150 in the mountains. Such distressinglyhigh death rates compare poorly with countries with similar GDP andgeographic settings, and raise questions about the coverage of MCH/FPservices, and about the effectiveness and coverage of health servicesin general. The chief causes of infant mortality are diarrhealsyndromes, acute respiratory infections, communicabLe diseases andtuberculosis, all of which account for 61% of all diagnosed motivesof consultation for children under one-year and are the consequencesof poverty, malnutrition and poor environment (Annex A.4).

1.22 Maternal mortality is high. Statistics for 1972 show anexcess of deaths among women aged 15-49, compared with men in the sameage group, attributable mainly to maternal mortality, which peaks betweenthe ages of 35 and 40 years. This suggests that maternal mortalitywas of the order of 530 per 100,000 births in 1972, as in other countriesat a similar stage of development (compared with 9.9 for the UnitedStates in 1978). Since 1972 better access to care has reduced maternalmortality drastically in urban areas. In rural areas, however, accessto MCE and family planning services and health and nutrition educationhave not improved significantly. The number of obstetrical emergencyadmissions as well as the number of deaths associated with hospitaldeliveries indicates that maternal mortality is still high in ruralareas.

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1.23 Morbidity. Morocco has been able to relieve itself from theburden of tropical diseases since most of them were controlled in the1970s, and the climate and terrain do not favor their rapid spread.Malaria, once endemic in the coastal plains, has been virtually eradicated,although a costly surveillance program is still necessary to preventreinfestation from outside Morocco. Scattered small foci of urinaryschistosomiasis, of which there were 7,400 cases in 1983, are undercontrol. In 1983 a Bank-financed assessment of the risk of malariaand schistosomiasis in areas of irrigation development, indicated amoderate potential for increase in some areas.

1.24 Morocco is going through a period of epidemiological transitionin which, while infectious diseases are still prevalent, chronic anddegenerative diseases are becoming increasingly important. Infectiousdiseases, favored by poor housing and sanitation and malnutrition, arediminishing but still prevalent among the poor and in rural areas.Chief among them are diarrhea, measles, acute respiratory infections,typhoid, hepatitis Type A, rheumatic fever, skin and eye infections,and tuberculosis. Morocco, however, has already reacbed the stage of"intermediate pathology", characteristic of urban populations: accidents,gastrointestinal dysfunctions, neuro-psychiatric disorders and addictionsand the need for dental, surgical, gynecological and obstetrical treatmentrequiring considerable radiological and laboratory support. The increasingdemand for secondary care is due partly to the rising expectations ofsome groups, but also partly to limited access to care on the part ofothers, which means that ailments easy to cure in their early stagesare often not treated until complications arise. Finally, the incidenceof chronic and degenerative diseases characteristic of industrial countries,such as cardiovascular diseases, diabetes, chronic lung conditions,cancer and occupational diseases, is rising as life expectancy increases.In Morocco, the overlapping in recent years of all three phases of thisepidemiological transition has imposed heavy burdens on the staff andfacilities of the health services and on national finances.

Environment

1.25 Limited access to potable water, particularly in periurbanslums and rural areas, lack of sewerage and inadequate housing contributeto the high incidence of infectious diseases in Morocco.

1.26 Water SuDDly. The Office National de l'Eau Potable (ONEP)under the Ministry of Equipment is responsible for supplying urban centerswith potable water. Distribution within the larger towns is managedby municipal enterprises ("regies") and in the smaller towns, by ONEPitself. In 1981, 72% of the urban population vas served by public watersystems - 35% by house connections and 37% by public standpipes. Onlyhalf of the latter vere within reasonable walking distance and servedfever than 500 persons. In rural areas only 7% of the population haveaccess to piped water, and the remaining 93% rely on unregulated vatersources - wells, cisterns, rainfall collectors, streams and ponds --

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often contaminated by humn ezcreta. Waterborse diseases, in particulartyphoid and dysentery, are still prime causes of desth and disease.NOPE, through its Service de l'Hygiine du Milieu, is responsible forthe control of water quality and the disinfection of some 100,000 waterpoints in the country. The Service conducted 124,000 disinfectionsin 1982, which represents little uore than 10Z of total needs, sincethe average water point should be treated ten tims a year. It is unrealisticto expect NOPE to do all this work, and the solution seems to be indelegating some of the responsibilities - particularly the enforcementof regulations - to municipalities, and eliciting comunity involvement.The Ministry of Agriculture and the Genie Rural made several attemptsto improve rural water supply by providing handpumps, motor pumps, reservoirsand water towers, to be operated and maintained by local communities;one year later, most of the facilities provided were underutilized orabandoned. This experience showed clearly that such interventions shouldbe tailored to local cultures if they are to produce health benefits.

1.27 Seweraoe. Urban sewerage systems have not been expanded tokeep pace with population, particularly in periurban slums. Medium-sizetonns often discharge untreated sewage into rivers. In rural areas,only 14Z of households have latrines and there is no provision for solidwaste disposal. A 1981 sanitation survey of 18,552 rural householdsin the Province of Settat revealed the deplorable state of the watersupply and sewerage systems.

1.28 Housint. Overcrowded and crude housing helps to spread disease.Over the last decade, private and public housing construction has notkept pace witb urban population. It is estimated that 252 of the populationlive in squatter settlements and another lOZ in housing dilapidatedbeyond repair. The 1982 Population and lousing Survey showed an averageof 2 nuclear families per household in urban localities, and 2.6 inrural areas.

1.29 In 1984 under the preparation of the proposed project, MOPHcarried out, with the support of UNICEF and the collaboration of theInstitut Agronomique Hassan It, a study of the socio-cultural determinantsof hygiene and sanitation in periurban and rural areas. The study identifiedsuitable interventions based on comunity commitment which would beimplemented under the proposed Health Development Project.

Health Services and Proiraus

1.30 Health Providers- There are four health providers in Morocco:the HOPE, the Caisse Nationale de la Securite Sociale (CNSS), the ArmedForces, and the private sector.

1.31 NOPE is the largest provider of health care; in 1982 it delivered6.4 million aedical consultations, 31.6 million units of nursing andpreventive care, and 5.8 million hospital days. The number of averagebealth contacts per person/year (1.8) and hospital days per 1,000 population

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(276) would suffice to ensure acceptable bealth and medical care ifthe quality and efficiency could be enhanced. Under the present conditionsand limited resources, however, MOPE can meet only part of the demand.MOPE is too often the provider of last resort that assumes expensivecare such am long-term treatment for chronic and psychiatric diseases,cancer and terminal illnesses. Other providers rely heavily on thepublic service to provide unprofitable treatment and technology. MOPHis the only provider of preventive care and public health programs.

1.32 The Caisse Nationale de la Securite Sociale (CNSS) was, untilrecently, a health insurance scheme that financed medical care providedmainly by the private sector and, to a lesser extent, by MOPH. In 1982the Caisse opened its own hospitals and clinics, and became a provideroffering medical care on a fee-for-service basis. In 1982 the CNSSprovided 500,000 medical consultations and 250,000 hospital days -about 71 of total medical care in the country. The CNSS offers thekind of service that attracts middle-income members, and competes aggres-sively with private physicians, but poorer people find it too expensiveand continue to seek care in MOPH facilities.

1.33 The Realth Service of the Armed Forces serves uniformed personneland their families, who form 5Z of the population.

1.34 Private physicians and dentists and private hospitals primarilyserve the higher-income groups. Because private physicians are oftenunderequipped and poorly monitored, they do not in general offer significantlybetter care than MOPH. While the rapid expansion of private practice,which took place in the 1970s, was welcomed as relieving the strainon the overburdened public services, the competition of the CNSS hasalmost brought this expansion to a stop.

1.35 Urban and rural populations often resort to other providersfor advice or treatment. In 1981 pharmacists and herbalist. provided7.5Z of primary care contacts. Although traditional healers are notlegally recognized and their activities are not recorded, they stillplay an important part in health care. Modern dental care is only availablein urban areas; the rest of the population resort to traditional healersfor extraction. MOPH operates a small preventive program in dentalhealth.

Government Health Policy

1.36 Although the GOM assigns high priority to health, its allocationof funds to the sector remains very low, both in relative terms at 1.2Sof GDP, and absolute terms at US$8.35 per capita in 1982, compared withAlgeria vith US$22.0, and Tunisia vith US$31.21. The Government's declaredpriority on health should be viewed in the light of this fundamentallimitation. The Government is aware of the pressing needs in health,population and nutrition; it is also aware of the modest but neverthelessrising demands of urban populations for care, and would like to come

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up with a cost-effective organization of health services. The lasttwo Plans reflect a change of health service pattern from the one basedon private practice and large hospitals, to one more appropriate toMorocco's present needs and financial situation.

1.37 The ambitious program of investment in large hospitals proposedin the 1977-80 Development Plau - 78% to hospitals and 16Z to basiccare -- was curtailed in the course of the ezecution of the Plan infavor of health centers and dispensaries. Nevertheless, operating budgetsfor basic health services remained insufficient. As a result, the primarycare system had a slow start.

1.38 The 1981-85 Develo2ment Plan marked a sharp departure fromthe previous policy, giving priority to basic health services and allocating55Z of the investment budget to basic health care and 45Z to hospitalsover the five-year period. This policy change was reflected in subsequentannual investment budgets: the 1983-84-85 investment budgets allocateda total of DR 314 million to basic health care and DE 199 million tohospitals. The Plan had set precise MCR, family planning, iiuunizations,health education and basic sanitation objectives for basic health.It also gave priority to improving the management of basic health servicesby decentralized programming, improved rinagement information systems,and upgraded training of personnel. Most important, the Plan recommendedthe exploration of alternatives to the present health care deliverysystem. To this effect, the Plan outlined the present Health DevelopmentProject in the provinces of Agadir and Settat, it set up a separateallotment of DR 60 million (US$6 million) in the investment budget,and requested Bank assistance for this purpose.

Public Realth Services

1.39 Since 1981, budgetary limitations, particularly those imposedon the operating budget, have hampered the implementation of the Plan.MOPE services are presently ill-prepared to meet the increasing demand.

1.40 Overall, the health delivery system is still centered on urbanfacilities. Hospitals, urban health centers and urban dispensariesstill retain most of the resources and prestige and continue to attractrural populations seeking care. As a consequence, the outpatient servicesof the urban facilities are overburdened - in spite of generous staffing- and the resulting quality of care is inadequate. In rural areas,rural health centers and dispensaries provide primary care without adequateback-up by urban services - i.e. laboratory and X-ray services - andwithout effective supervision and logistical support. The shortageof drugs, which will be discussed in paras. 1.3 to 1.67, drasticallylimits the efficiency of the services. Outreach activities are coordinatedby the "Service de l'Infrastructure d'Actions Ambulatoires Provinciales"(SIAhP): male itinerant nurses, based in each dispensary, are expected-to make monthly visits to every household in the cosmunity to providefirst aid, health education, sanitation advice and to take blood samples

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for malaria control. However, the monthly visit *chedule provedunrealistic. As the itinerant nurse lackc the most basic drugs andonly collects blood samples, his credibility is low - in sao areashe is openly rejected by the population.

1.41 Because of these weaknesses, the actual coverage of publichealth programs is low. MCR and PP reach only 301 of their target popu-lations; prenatal care covers only 5.4Z of all pregnancies; only 112of deliveries take place in maternities; less than 201 of infants fromO to 2 years of age are monitored by child health clinics, nutritionprograms reacb only a small percentage of the population at risk; visitsper person/year declined from 2.45 in 1976 to 1.8 in 1982; andimmunization programs bad reached only 451 of the target group by 1983.

D. Sectoral Resources

Phvsical Resources

1.42 Morocco's hospital network is on a small scale for a middle-income country, but is generally sufficient. It includes 80 institutions:2 university hospitals for specialized care, 44 general hospitals and34 bospitals for long-term care. There are 24,913 hospital beds, or1.2 beds per 1,000 population, a minimum by international standards.Making better use of existing beds is a higher priority than providingadditional beds. The network, as it is, could provide acceptable coverageif managment and performance were improved; bed turnover is slow, andaverage occupancy low at 63.51 (Annex A.8). The radiological, diagnosticand laboratory equipment is generally appropriate, but lack of maintenanceresults in costly repairs and replacements. There is no technical unitin charge of hospitals -- neither hospital technology nor hospital manage-ment -- in MOPH. The Ministry, however, sees an urgent need for studieson hospital organization and management with a view to improving efficiency,cost effectiveness, and uaintenance. The Bealtb Development Projectwill finance such studies.

1.43 The outpatient services consist of 840 dispensaries and 297health centers. Most of the existing dispensaries are rudimentary,and poorly equipped. Facilities are spread too tbinly and coverageis inadequate. According to MOPE's standards, there should be one healthcenter for every 45,000 people and one dispensary for every 15,000 people.The actual ratios are one center for every 84,000 people and one dispensaryfor every 25,000. To meet the standards countrywide, some 90 additionalcenters and 460 additional dispensaries would be needed. The detailedplanning exercise carried out for the preparation of the project confirmedthat a 55.T expansion of the physical facilities was necessary to reach801 of the population.

1.44 Outpatient and outreach services rely beavily on transport,vhich accounts for 321 of their recurrent costs. The average itinerant

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nurse travels 19.3 km per working day. The average four-wheel vehicletravels 30.000 km per year, often in rugged terrain, and lasts two anda half years. The choice of vehicles is still sn unresolved problem.HOPE plans to test alternstives to the current bicycles, mopeds andlandrovers, such as 125-cc motorcycles sad light pick-ups. It is alsoexploring incentives for the proper operation and maintenance of vehicles,such as bonuses, transfer of the vehicle to the user after three years,leasing and concessionary loans for the acquisition of vehicles.

Hunan Resources

1.45 Medical Personnel. The training of physicians is the responsi-bility of the universities under the supervision of the Ministry ofEducation and MOPE. There are at present 4,000 physicians in the country.evenly distributed between public and private practice. The physician/population ratio reached 2 per 10,000 by mid-1984, and is increasingrapidly as 700 new physicians graduate annually. Even if this ratiois still low, compared vith other middle-income countries, it is notpossible to determine how many physicians will be required or what formtheir training should be until MOPH defines the long-run structure ofthe bealtb sector through the present project. In 1978, the two medicalschools agreed to reduce their total output to 400 per annu and tostrengthen training in public health and preventive medicine. Two smalldental schools opened in 1981 and will progressively expand their studentintake. A school of Pharmacy is scheduled to open in 1985. In themeantime, the majority of dentists and pharmacists are still trainedabroad.

1.46 Administrative Personnel. Over 170 graduates wf the EcoleNationale d'Administration Publique (ERAP) are now employed in MOPE,chiefly as managers of the big bospitals and provincial services. In1983 the ENAP, in collaboration with MOPH, created a s*pcialized sectionin Public Reath Administration. The new curriculum comprises publicaduinistration, health administration and economics and hospital management.This section vill provide MOPE with young and qualified managers whowill be instrumental in improving the management of the services.

1.47 Paramedical Personnel. The training of paramedical personnel,conducted at the College of Public Health and 48 schools for nursesand technicians, is the responsibility of MOPH. Paramedical personnelconsist of three levels of nurses and technicians: a) 16,000 basicnurses, wbo provide the rank and file staffing of the services;b) 6,000 certified nurses and technicians, who provide the intermediatestaffiug; and c) 400 specialized nurses or "cadristes", who fill keypositions in management, supervision, training and research. By andlarge, paramedical personnel are well-qualified and well-distributed.Details of categories of personnel are given in Annexes A.5 and A.6.

1.48 MOPH has a total payroll of 29,000 persons, including 1,100physicians, 18,000 paramedicals and 6,000 support personnel. Unlikemany developing countries, the pyramid of personnel is well-balanced

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and there are no serious shortages. Liberal estimates of future manpoverrequirements, made in the prosperous oid-1970c encouraged a substantialezpansion of training capacity and of the staff of the public healthservice. In 1982 severe budgetary restrictions necessitated the curtailmentof hiring. MOPH will reassess its manpower requirements in the lightof the present financial situation and of the cbanging pattern of thehealtb services. In particular, it will have to take account of theSolloving factors: a) the basic health services will require auxiliarypersonnel for rural work, with a shorter training period and lower salaries(one year of training after two or three years of secondary educationis envisaged); b) in isolated areas, utilization of comunity healthworkers, community uidwives, and traditional birth attendants is bei'gexplored; c) the need for fully qualified nurses, technicians (ASDES)and cadristes will increase; their training should be intensified.

1.49 More generally, NOPE considers the desirability of trainingtechnicians with possibilities of self-employment, such as opticians,herbalists, dental hygienists, dental assistants, physiotherapists,and prostbetic technicians, who could serve in the private sector, andthus impose no burden on the national budget.

1.30 NOPE, therefore, sees the need for a comprehensive reviewof healtb mAnpower requirements covering the public, parastatal andprivate sectors. However, NOPH does not envisage unilateral changesuntil the Government defines the role of specific training progrms,such as those carried out by NOPH within the context of its new VocationalTraining Strategy, presently under preparation with lank assistance.

1.51 The quality of nursing education is generally adequate. However,the training of certified nurses has been impaired in recent years becauseof inadequate facilities. The health component of the Bank's ThirdEducation Project, appraised in 1976, provided for the constructionand equipment of a College of Public health in Rabat, but it was onlypartially implemented because of MOPE inexperience of lank projects,and due to time-consuming administrative procedures. Eventually, theCollege was constructed under the project, but not provided with a library,textbooks, laboratory, demonstration equipment and vehicles. The HealthDevelopment Project will finance the completion of this component.

Financial Resources

1.52 Total public health expenditure amounts to about 1.22 of GDP,i.e. much less than in other middle-income countries, such as thePhilippines and Syria (2.4S), Zambia (3.4Z) or Jordan (5.2S). Theyrepresent only 32 of total goverment outlays, a proportion which hasdeclined from 7.8Z in 1965 to 3.01 in 1983 and a budgeted 3.51 for 1984,as shown in Annex A.9. As the COM fionaces 90S of public health expenditure(81 are covered by the national social security system, and the remaining2S by individual households), this decline has serious implicationsfor national health.

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1.53 Annual cgaital expenditure on health has fluctuated fromDR 244 million in 1983, compared with DR 300 million in 1982 and a projectedfigure of DH 139 million (US$15 million) for 1984, and has fallen steadilyas a proportion of total public investment, from 3.2Z in 1965, to 1.3Xin 1983 (see Annex A.9). Until the late 1970's about 70S of this capitalexpenditure was on hospitals, but under the 1981-85 Development Plan,the share of hospitals is expected to decrease to 60Z.

1.54 Oneratinf expenditures also have declined as a proportionof total public recurrent expenditure, from 9.7Z between 1965 to 4.5Zin 1983; no change is expected in 1984 as these are budgeted at DE 918million, or 4.8% of Government's total operating budget. Salaries absorban increasing share of the sector's current resources and their proportionincreased from 56.4% in 1965, to 70.52 in 1983 and 74.3Z in 1984. Thistrend has had a serious negative impact on the sector, especially atthe outreach level, as less and less resources are left to cover otheroperating expenditure, such as drugs, maintenance and transport, resultingin the perceptible deterioration of the quality and coverage of services.

1.55 As a step towards improving the finances of the public healthservice, MOPE explores possibilities of cost recovery. Recent surveyshave shown unexpectedly high household expenditure on health care anddrugs, thus demonstrating people's willingness to pay for health care.Hovever, it would be unrealistic to expect people to pay for servicesof the present quality until the reputation of the system has been restored.To determine the feasibility and range of cost recovery for preventiveand curative care for ambulatory and hospital servicos, MOPE gives highpriority to the analysis of current costs and future sector financingfor vhich studies are included in the Health Development Project.

E. Sectoral Issues

Health Care Delivery System

1.56 Since the late 70s, MOPH has given priority to continue deployingthe primary care system progressively over the entire country. However,MOPE underestimated the technical, financial and managerial problemsof the task. As a result, the system remains incomplete and has neverbeen in full operation, with all necessary inputs in any area. As MOPHlacked capacity to monitor the system, early signs that it vas not functioningaccording to expectations were misinterpreted. In 1977 operating budgetsdeclined in real terms. The scarce supplies were concentrated in hospitals.Implementation of the PHC system slowed down considerably. -Outreachactivities, in particular, were soon crippled by a variety of shortagesand came to a minimum when the drug supply dropped in 1980. As a result,Norocco is presently maintaining an ineffective PBC system at high cost.

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1.57 NOPE nov appreciates the technical difficulties and, withthe help of field staff, bas improved the design of the PlC system. Thetechnical difficulties relate to the targeting of activities, utilizationof appropriate technology, supervision, delegation of responsibilities,referral and back-up by rural bospitals. MOPH has clearly identifiedthese problems in the 1981-85 Development Plan and is ready to deploythe new PHC scheme in three provinces under the Health Development Project.

Nanaaement

1.58 NOPE is responsible for the policy making of the public sectoronly. The parastatal and private subsectors have developed withoutcoordination, resulting in duplications and social inequities. Thecapacity of MOPE to plan its own operations and control resource allocationand costs is limited. Decision-making in WMQO is still highly centralizedin the office of the Minister and the Secretary General. The Directorateof Technical Affairs (DAT) is responsible for health programs and theDirectorate of Administrative Affairs (DAA) is responsible for the day-to-daymanagement of the Ministry (Annex 1.1).

1.59 MOPE has had in the past a limited planning responsibilityfor coord4uating all agencies - public and private - in the sector.The Ministry has also demonstrated a limited capacity to program itsinternal operations. Since 1980, however, following a WHO recoumendationsupported by successive Bank miscions, the 'Division de l'lnfrastructureCharg&e de la Planification (DICP) has been strengthened. In 1983 and1984, project preparation helped tu further improve the DICP by attractingadditional qualified staff and opening vider sectoral issues to discussion.

1.60 Since 1981, USAID-financed technical assistance, aimed atimproving the management of MOPE, has achieved results in several areas,particularly in computerizing DICP's operations - inventories, recordsystems, processing of statistical, research and personnel data. Broadermanagerial or organizational issues have been addressed. MOPH is presentlyconmitted to improving day-to-day management before any major structuralreform could be envisaged. The Ministry has identified key areas inmanagement to be strengthened under the project.

Supply of Basic Drums

1.61 Morocco consumed DE 800 million (US$95 million) vorth of drugsin 1983, i.e. DE 40 (US$4.76) per capita. Of this total, MOPE distributedDR 47 million (US$5.6 million) worth or less than 6Z, and of this amountonly US$0.5 million vorth, i.e. 0.5Z of national consumption, went toprimary care, the rest going to hospitals. Primary care services arepresently supplied with an average of US$0.15 worth of drugs per person/year;MDPE estimates instead that a minimum of US$0.40 per capita is necessaryto support primary care.

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1.62 Between 1982 and 1984, MOPE, vith the assistance of USAID,UNICEF and WHO, oade several studies which identified the technicaland managerial deficiencies of the present Drug Supply system:

(i) Technical deficiencies: There is no standard list of drugs,and the hea'th services. and hospitals base their requisitionson individual preference or on what they used in the previousyear. A survey of the demand for primary care (Annez A.4)coupleted in 1984, led to a standardization of treatmentsand a standard list of basic drugs that vill be tested in1985. The most common errors of prescription have beenidentified, - errors of indication, dosage and duration oftreatment as vell as utilization of antibiotics as placebos.Finally, most drugs are supplied in bulk to dispensaries andhealth centers which, lacking suitable packaging material,dispense them in paper cones without labels and instructions.Patients' compliance with treatment instructions is poor.

5ii) M_nexerial deficiencies: Responsibilities for the supplyof drugs are scattered in different services of the Ministry:the allocation and control of drug supplies rest with theauthority of the Service de l'Equipement; procurement of drugsis under the Service du Budget, both under the DAA; reception,storage and control of stocks are the responsibilities ofthe Central Pharmacy (CP) under the DAT, while standardizationrests with the DICP. Little coordination ezists between theseservices, clearances require moving papers back and forth.Procurement is not carried out efficiently. There are usuallydelays through the several services involved in specifyingitems to be procured and in evaluating tenders. In addition,manufacturers do not submit tenders for all items and frequentlyfail to deliver on schedule. and finally, pjyments to providersare made with considerable delay. Druge are stored togetherwith medical equipments and furniture, as well as chemicalsand flammables. The CP"s dilapidateed wareh,%use makes storageunsafe and the handling of drugs and chemicals hazardous.Inventory control procedures are obsolete.

1.63 Taking into account all negative factors - inefficientselection and procurement, losses, thefts, misprescription and poorcompliance -- less than one-third of the PHC drug allocation actuallyproduces health benefits. A drastic improvement of the public sectordrug supply system is essential.

1.64 For its own use, MOPE prepares some forty basic drugs in theCP's formulation unit. The formulation laboratory operates in unsuitableand dilapidated premises, processing does not comply with safety regulations,packaging is unsafe and unattractive. In order to simplify, reduceor even discontinue the formulation of basic drugs, NOPE has exploredseveral alternatives such as procurement of brand-name or generic drugs

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on the international and national markets, contracting with the localindustry and, finally, 'Toll Formulation" by which MOPE would buy inter-mediate ingredients on the open international market and contract vithlocal industry for their final formulation. Local industry has indicatedinterest in toll processing the most complex and expensive of the basicdrugs, an alternative which will greatly simplify NOPE formulation.The various alternatives considered by the Appraisal Mission are describedin Annex G.

1.65 The 1981-85 Health Development Plan provided for the reorganizationof HOPH's drug system and improvement of the supply of basic drugs. Tothis effect, the Plan earmarked DR 12 million (US$2.3 million equivalentin 1981). This amount is allocated in the 1984-85 Loi des Financesas counterpart funds for a drug component of the Health DevelopmentProject.

F. Summary Assessment of the Sector

1.66 Since 1980 MOPE has recognized the need to give priority toprimary health care, but budgetary limitations have left the reorganizationof HOPH incomplete and health programs -- family planning, i munizations,MCH, nutrition - unconsolidated. Over a period of economic stagnationand diminishing family incomes, high fertility, rapid demographic growth,unresolved health problems, malnutrition and poor sanitation may inflictirreparable biological damage to tbe poprlation with severe long-termconsequences for the economic and social development of the country.

1.67 The sector faces several issues: the ineffective system ofhealth care delivery, presently biased towards urban care; the absenceof policymaking in HOPE and consequently the lack of coordination betweendifferent health care providers; the weakness of HOPH's internal planningand management; inefficient use of resources by the hospital subsector;insufficient overall financing of the sector; MOPE's disorganized andcomplex pharmaceutical supply, resulting in a severe shortage of basicdrugs which threatens the credibility of the entire system.

1.68 The sector has, however, valuable assets as compared to manycountries at the same stage of development: first, its well-qualifiedand well-balanced health manpower, with neither overproduction of doctorsnor shortages of technicians. Second, its unsophisticated hospitalnetwork which, once made more efficient, would not impose the customaryoverwhelaing burden on the sector finances. Third, the realistic butpositive attitude of key executives in NOPH towards priority interventions- family planning, primary care and managerial improvement. NOPH iskeenly aware of its own limitations. It recognizes that at presentit is impossible to expand its facilities or assume new responsibilities,and that a period of consolidation and reorganization is necessary before

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expansion can be resumed. The technical and managerial aspects (f thenew system have been carefully studied and tested on a small scale,and are now ready for the implementation of the changes outlined inthe Plan.

G. Government's Obiectives and Bank Role

1.69 The Bank's overall strategy in Morocco pursues three majorobjectives: a) financing high yielding export-oriented or import-substitution activities as well as supporting infrastruckure and services;b) increasing domestic resource mobilization and budget savings by,among otbers, improved productivity and efficiency; and c) improvingincome distribution by, among others, improving basic social servicesin rural areas. The Bank's objectives in the social sectors includethe shift from capital and foreign exchange intensive bospitals to expandingbasic bealth services to uaximize affordability and access to low-incomegroups.

1.70 Government's long-term objective in population is definitelyto control demographic growth by stepping up population activities progress-ively, and raising targets for contraceptive prevalence in order toreach a population of 30 million or less at the year 2000. In healthand nutrition, Government's mid-term objectives are: to minimize thebiological impact of the economic crisis on the population; to improveM0PE's management and hospital performance; and to identify cost-effectivealternatives to the present health and nutrition programs. The long-termobjectives are to secure a financing scheme for health care, and toeliminate pockets of malnutrition by raising domestic food production.

1.71 The present Health Development Project stems from Government'sobjectives and discussions with the Bank, since 1979, for the preparationof the 1980-85 Realth Development Plan, which incorporates the developmentof cost-effective health care delivery systems with emphasis on primarycare and family planning. The Plan relies cn a Bank-financed projectto test an alternative to the present health system and set the basisfor its countrywide implementation. The Bank financing will complementother donors' technical assistance and provide the financial stabilityto bring about the desired changes.

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II. THE PROJECT

A. Proiect Concept and Obiectives

2.01 The project will assist NOPE in strengthening and acceleratingthe shift avay from an urban-based hospital-oriented health system benefittinga limited segment of the population towards a more cost-effective systemof primary care emphasizing outreach activities in the rural areas.

2.02 The project has two interrelated objectives which are statedin the 1981-85 Development Plan of MOPE:

(a) Strengthening primary health care delivery including familyplanning - in three provinces, totalling 1OZ of the country'spopulation. Project implementation would be closely monitoredand accompanied by operational research, to allow for continuousadjustments resulting in a viable alternative to the presenthealth care delivery system.

(b) Strengthening the capacity of MOPH at central and provinciallevels to make plans for the health sector, to train staff,to conduct research and evaluation, and to administer thepublic health service, as a necessary condition for a large-scale extension of the health care delivery system to therest of the country.

B. Proiect Composition

2.03 The project will consist of four components, the first ofwhich will meet the first of the above objectives, and the others thesecond.

(a) Primary Health Services: The primary health care system envisagedin the 1981-85 Health Development Plan, but not fully implementedand revised in the light of experience, will be fully deployedin three provinces - Agadir, Settat and Taroudant - witha view to future extension of the project to the rest of thecountry. The necessary investment in additional buildings,equipment and vehicles will be made in the t.ree provinces.

(b) -_na ement. The project will provide technical assistance,training and equipment to strengthen the capacity of MOPEto manage the public health service, to formulate policy andplans, provide coordination for the health sector as a whole,and to conduct research and evaluation.

(c) Trainin- and InformationlEducation and CommuDication (IEC). Theproject will strengthen capacity to train paramedical personnel

- 21 -

and produce IEC X. '-rials by providing equipment for a trainingcenter constructed inder the Third Education Project. Itwill also provide equipment, vehicles, and technical assistancefor the production and dissemination of IEC materials.

(d) SuDDly of Basic Drbus. The project vill help establish acoordinated system for the procurement, storage, formulationpackaging, distribution and control of drugs for the publichealth system by providing construction, equipment, trainingand technical assistance.

C. Proiect Description

Primary Health Services Component

2.04 The first component vill support the deployment and operation,in a limited geographical area, of the primary care and family planningscheme envisaged for the entire country. Special attention vill begiven to the cost-effectiveness and replicability of six core programs- Immunization, Family Planning, Maternal and Child Health, Nutrition,Front-Line Care, and Basic Sanitation. The implementation of this componentvill be carefully monitored and evaluated to obtain guidance for thefuture expansion of the primary care system.

2.05 This componynt vill be carried out in three provinces - Agadir,Settat and Taroudant -- with a total population of 1.9 million in1984 (9.2Z of Morocco's total population). The three provinces wereselected as representative of the entire country in such re3pects asgeographic features, ecological areas, socio-economic strata, ethnicand linguistic groups, fertility rates and epidemiological profiles,so that the experience gained in the course of the project vill serveas a guide for its replication in other provinces. Description of thethree provinces and baseline data are shovn in Annex 3.1 to B.6.

2.06 The primary health care and family planning scheme will comprisesix core programs which vill be implemented as follovs:

(a) Imunizat-ion: The project vill support in the three provincesthe nationvide imunization program designed with UNICEFassistance against diphteria, tetanus, whooping cough, measles,polio and tuberculosis. The program vill be carried out throughcontinuous vaccination by the health facilities and mobileteams.

1In 1983 the Province of Agadir was split in two: Agadir and Taroudant.Consequently, in April 1984, MOPH established a new Medical Directoratefor the Province of Taroudant vhich is included in the proposed project.

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(b) Famill Plannint: The project will implement the VDMS approach(as described in para. 1.09) in the project area in the sameform as in the other provinces where it is in operation withUSAID/UNFPA support. Contraceptive prevalence in the projectarea is targeted to rise from present 22% of NKRA to 33% in1989. The program strategy is three-fold and cowrpises:a) reaching rural NWRA, b) improving continuation rates, andc) offering a vider range of modern contraceptive methods.

(c) HCR Care: The project will deploy MCH services further tothe periphery. This will greatly improve the monitoring ofpregnancies and under five-year-old children; it will alsoimprove the conditions of home deliveries and secure hospital-ization of high-risk deliveries.

(d) Nutrition: The project will improve the nutritional statusof infants, preschool children, pregnant and lactating womenthrough pre- and post-nsatal care and clinics for childrenunder five years of age; through active detection of malnutritionby itinerant agents, mobile teams or family health mobileunits; and through effective approaches to nutrition rehabilitation.

(e) Front-Line Curative Care: The project will expand and improvecurative care by standardizing diagnostic and treatment procedures,by providing laboratory back-up, and improving referral andthe supply of basic drugs.

(f) Basic Sanitation: The project will iutensify the surveillanceand continuous disinfection of wells and cisterns, and improvesolid waste disposal. It will also enhance the domestic useof vater through locally-designed house improvements.

The planned interventions were carefully designed on the basis ofexperience in Morocco and other countries, witb technical assistancefrom WHO, UNICEF and USAID. Technological innovations were reviewedat all staff levels. Detailed contents and objectives for the six coreprograms are given in Annex C.

2.07 Delivery System. The six core programs will be deliveredby multi-purpose staff sharing the same facilities. The type of staffand facilities in any given area will be adapted to local conditions- terrain, population density and socio-economic level. Project preparationincluded extensive field surveys of the rural population, and systematicconsultations with field staff, civil authorities and local communitieson the type of bealth service delivery most suitable to the accessibilityand degree of dispersal of population. On this basis, it vas decidedthat six types of service, or "stratigies", each employing differentmixes of fixed facilities and outreach techniques, vill meet the needsof all areas. For each locality, village or hamlet, a formal agreementwas reached vith civil authorities and coaunity leaders on the mostsuitable strategy. Unlike theoretical schenes proposed in the past,

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these strategies are realistic and tailored to the needs of the population.Details on the strategies are given in Annex D.

2.08 The project will provide the following elements for the implemen-tation °f this component: the construction of 10 Basic Rural Dispensariesof 68 a each; 38 Rural Dispehsaries of 104.6 a ; housing facilitiesfor 258 staff in distant rural areas; 10 2rural health centers of threedifferent sizes with an average of 403 m ; 2 urban health centers and2 smll rural hospitals of 2,200 m . It will also provide for substantialimprovement or extension of existing facilities: 33 basic rural dispensaries,41 rural dispensaries, 32 rural health centers, 8 urban health centers,2 urban maternities, and 3 rural hospitals. Architect fees and supervisioncosts will be financed under the project. At negotiations, MOPE hassubmitted the final architectural designs for dispensaries, and healthcenters Type 1, 2, and 3; preliminary dravings for the hospitals ofTaliouine and Ouled Teima, and dravings for upgrading the hospitalsof Taroudant, Benahmed and Ait Baha, as well as the revised correspondingequipment lists, for Bank approval. The location of the new or upgradedfacilities is shown in maps IBID 18651, 18652, and 18653.

2.09 The project will provide equipment, and furniture and vehiclesfor the additional and upgraded facilities as well as the followingvehicles: 21 ambulances, 37 four-wheel arives, 27 light sedans, 2 trucks,49 uotorcycles and 244 mopeds. It will also provide for the refreshertraining carried out locally for medical, paramedical and support personnelinvolved in primary health care, followed by continuing education ofall personnel. The project will also provide for the incremental recurrentcosts of expanding health programs in the three provinces - supervisionand coordination, transportation and additional supply of basic drugs.

Management Component

2.10 The component will improve the management capabilities ofMOPE and strengthen its role as policy-maker for the health sector.

This will be achieved by strengthening its planning capacity, by estab-lishing a capacity to carry out evaluation studies, and by improvingadministrstive procedures.

2.11 Planning. By the end of 1985, MOPE is expected to have finalizeda comprehensive plan for the sector, to be included in the 1986-88Development Plan. This sectoral plan will be prepared in coordinationwith other public and private agencies in the sector. NOPE will thenmonitor the implementation of the plan and prepare an eztension of baaicservices to other provinces. During the final stages of project preparationthe DICP has expanded its staff, and at negotiations assurances wereobtained that the Division de l'Infrastructure Chargee de la Planification(DICP) at all times will continue to carry its operations with full-timequalified and experienced staff in adequate numbers. The project villfurther strengthen the DICP and develop its capacity in seven areas- long-term planning, short-term planning, manpower planning, healthprogramming, physical planning, biomedical and hospital technology,research and evaluation.

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2.12 The project vill provide the DICP vith computer equipment,furniture, office supplies and vehicles. It vill also provide 29 monthsof fellowship for post-graduate training in health planning and programming,health economics, manpower planning, and management information systems.Finally, the project will finance 22 m/i of local consultants to supplementthe technical assistance provided by the two advisers in health planningassigned by WHO to the DICP.

2.13 MOPH Management. The project will improve NOPH's overalladministration. The project will follow up on previous studies andtechnical assistance financed by USAID and WHO on management informati.onsystems, and will in addition support the improvement of administrativeprocedures in four priority areas already identified by the Ministry.Under the coordination of the Secretary General, NOPE staff assistedby local and foreign consultants vill carry out a study on four managerialareas: a) program budgeting and resource allocation; b) procurementand bidding procedures; c) civil works and maintenance; and d) managementof personnel. On the basis of the study, an action plan vill be developed,which will address the organization of services, streamlining of procedures,retraining of staff, and modernization of office technology. At negotiations,assurances were obtained that the action plan vill be prepared and submittedto the Bank by December 31, 1986, and that the Borrower will carry outsuch action plan as shall have been agreed vith the Bank.

2.14 Studies. The project vill include a program of studies designedto support the planning and management process. Agreement was reachedduring project appraisal on general terms of reference for the threeproposed studies:

i) Healtb Services Monitorina. NOPE will implement a comprehensivemonitoring and evaluating system for the present project,including family planning programs, as a first step towardsmonitoring the progress of the Plan as a whole. Data collectedby health facilities will be processed and complemented byoperational research or evaluative research. Conclusions onreplicability of the project are expected by end of 1987, andwill be included in the mid-term evaluation (para. 4.14).

(ii) Study on the Financins of the Realth Sector. The study villanalyze the availability and allocation of funds, and theefficiency and equity of the present and alternative financingschemes. The study is assigned high priority by the GOC andMOPH. The GON will appoint a Steering Committee with theparticipation of the Ministries of Finance, Planning andEconomic Affairs for the coordination of the study vwich willbe conducted in two phases. The first phase, diagnosis, isalready under way and will be completed by mid-1986; the secondphase - exploring alternatives of financing - will be completedby end of 1988 to provide guidance for the implementation

- 25 -

of the 1986-88 Development Plan. At negotiations, assuranceswere obtained that the Borrower will appoint by December 31, 1985,an interoinisterial steering comittee for the coordination ofthe Study. Assurances were also obtained that final results avdrecomendations of the study vill be furnished and discussed withthe Bank by December 31, 1988.

(iii) Study on Hospital Manazeent. Since hospitals absorb 72Zof NOPH's operating budget, the study will focus on hospitalperformance, cost containment and possible methods of costrecovery, in accordance vith the alternatives of the studyon financing. The final report is expected by the end of1988. At negotiations, assurances were obtained that theGovernment will furnish and discuss with the Bank by December 31,1988, the findings and recommendations of the study and willimplement such recoomendations as shall have been agreed withthe Bank.

All three studies will be managed by the DICP. The detailed descriptionand timetable of the studies are given in Annex F.

2.15 For the Studies subcomponent, the pro3ect vill provide:a) technical assistance consisting of 17 m/i of foreign experts and177 m/m of local experts from consulting firms and universities;b) training through 72 fellowship/months for training overseas as wellas local seminars; c) computer and office equipment. The project willalso provide for local costs -- transportation, supplies, dataprocessing -- as well as publication of the results of the studies.

Training and IEC Component

2.16 The component will remove two obstacles standing in the wayof improving the health system: a) the incomplete training that hasbeen given in recent years to the mid-level cadres - Specialized Nurses,Technicians and Cadristes vho are presently crucial .for the operationof the system; and b) the insufficient IEC capacity to support the risingdemand for training of health personnel as vell as priority programssuch as family planning and PHC. This will be achieved by equippingthe College of Public Health and improving the production and utilizationof training and IEC materials.

a) Equipment of the College of Public Health

2.17 The project will provide educational materials and equipmentfor the training of paramedicals in Rabat. This component was appraisedin 1976 under the Third Education Project, which vas only partiallyimplemented, as described in para. 1.51. The College is nov operatingat full capacity, and enrolls annually 720 paramedical trainees on two-yearcourses (120 nurses, 80 psychiatric nurses, 40 physiotherapy assistants,80 pharmaceutical assistants, 40 radiology technicians, 80 laboratory

- 26 -

technicians, 40 anaesthetic. assistants, 80 sanitarians, 40 statisticiansand 120 cadristes). However, only theoretical instruction can be givenat present, and training is severely handicapped by lack of textbooksand bilingual (French and Arabic) handouts, and equipment for demonstrationsand laboratory work.

2.18 The project will provide computer and other educational andtechnical equipment in the form of textbooks, audiovisual and libraryequipment, materials for practical training in laboratory, clinicaland surgical nursing, anaesthesiology, physical therapy and sanitation.The project will also provide vehicles for the transport of studentsand instructors for hospital, community and field practices. Printedmaterials other than teztbooks will be provided by the training andIEC subcomponent described in the following paragraphs.

b) Production of Training and Information/Education/ComunicationMaterials

2.19 The project will strengthen MOPH's capacity to prepare, produceand distribute printed materials -- manuals, handouts, instructionalmaterials, and audiovisuals.

2.20 The Health Education Unit of the Population Division alreadyacts as MOPH's printing and IEC office, but lacks adequate capacityto meet its own needs as well as those of other branches of MOPH (seepars. 1.10). The Health Education Unit is presently underequipped toproduce the quantity and quality of materials required.

(a) The College of Public Health and the 48 schools of nursingin the country are the chief users of educational materialsin the sector, and require 70,000 copies of various manuals,handouts, and other educational materials annually. Theprovincial health services require 40,000 copies annuallyof operating manuals and continuing education materials.

(b) The supply of pamphlets, leaflets, posters, slides, TV videocassettes and audiotapes to be used in IEC support progrinsfor family planning and primary care (see para. 1.10). isdeficient in quantity and quality. There is also a shortageof transport and equipment for the dissemination of IEC programs.

2.21 The project will improve the Population Division's capacityto produce training and IEC materials. It will provide printing, graphicand audio-video equipment, as well as supplies, to complement the equipmentwhich has been sporadically provided over the years by different donors- USAID, UNICEF, RHO, UNFPA. The project will improve the qualityof training and IEC materials by providing 44 fellowship/months forthe training of staff, and by providing for the diversification andpre-testing of materials.

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2.22 Finally, the component vill address the deficient disseminationof IEC in rural areas - a lingering problem that affects principallyfamily planning, nutrition and sanitation programs (see paras. 1.10and 1.16). The project vill improve the delivery of IEC by the healtbservices in rural areas by using lighter and more versatile mobile units,shorter and simpler video spots, mainly as support for presentati-onsin Arabic or Berber, followed by debates with the coumunity. The projectwill provide 32 light mobile units - 17 four-wheel drives and 15 lightpick-ups vitb audiovisual equipment for use in rural areas. The projectwill include the incremental operating costs of the IEC program. USAID,UNICEF and WHO vill continue to supply technical assistance for thedesign, pre-testing, production of IEC materials adapted to rural area4.The program will be closely monitored for adjustments and evaluatedperiodically. At negotiations, assurances were obtained that the Borrowerwill prepare and submit to the lank for coaents, by December 31 ofeaeb year, the detailed annual program, including targets and timetables,for the production and utilization of IEC materials.

Suinly of Basic Druzs

2.23 In view of the paramount importance of a dependable supplyof basic drugs for primary bealth care and the present disorganizedstate of drug manufacture and distribution in the public health service,this component is designed to reorganize the entire d_ug supply systemof the public sector.

2.24 The private sector will continue to distribute about 952 ofthe drugs used in Morocco. In addition, it will continue to supplymost of MOPH's drugs, either by cosmercial manufacturing or by tollmanufacturing. Over the project duration, the Covernuent plans tomaintain, as a minimum alternative, its total allocation for drugs atpresent level, in real terms, with only a 3% annual increase to matchdemographic growth. Within this allocation, MOPB -- by judiciousselection of drugs, progressive utilization of generic drugs, improvedprocurement, cost saving formulations, reduction of thefts and losses,and improved dispensing - will be able to increase by 60% the avail-ability of basic drugs for PBC.

2.25 The project will reorganize MOPH's Drug Supply System underthe authority of a newly created Drug Supply Unit (Unite d'Approvisionnementen MNdicaments - UAN) which will have full responsibility for the severalsteps of the drug supply process - budgeting, accounting, procurement,control of stocks, contracting with the pharmaceutical industry, formulationand packaging of ba.iic drugs and distribution to the provinces. TheCentral Pharmcy vill become a central supply unit dealing exclusivelywith furniture and medical equipment. Responsibility for the qualitycontrol of pharmaceuticals will remain under the National ControlLaboratory. The sequence of operations to be performed, as well ascontrols and feed-back mechanisms, are shown in the diagram in Annex

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G.l. The UAM vill be established within MOPH vitb its ova individualizedbudget and will have full authority to carry all operations requiredto ensure the supply of drugs which are mhown in Annex G.2. At negotia-tions, assurances were obtained that the Borrower will establish andmaintain the UAN with terms of reference and staff acceptable to theDank, to be responsible for all steps of the drug supply process, andwill ensure it is provided, through individualized annual budgetaryallocations, with sufficient funds for its drug supply operation overthe duration of the project. The establishment of the UAM will be acondition of disbursement against the drug supply component.

2.26 The project will improve the UAN's management, storage, formu-lation and packaging capacity:

(a) Manatement. The management subcomponent will simplify thesubmission of orders by the provinces, and base local andinternational procurement on an International PharuaceuticalMarket Information System (IPKIS). It will improve budgeting,disbursement, contracting with the private sector for tollformulation, control of stocks -- including emergency stocks- and distribution. To this effect, the project will providefor construction and equipment of an administrative office,and for equipment and furniture, computer equipment and telexequipment, training of staff, contractual services with aninternational market information system, and technical assistancetbrough 10 m=/ of training abroad and 20 m/i of foreign experts.

(b) Storage and Haodlita of Drugs. The proj t will improve theprocedures for customs clearance, transportation, reception,sampling for quality control, warehousing, internal handling,storage of finished products, packing, dispatching and distributionto the provinces. The storage and handling of some 280 pharm-ceuticals and cbemicals, including flamma le gases and liquidsas vell as toxic material and insecticides, require appropriatefacilities regulated by safety and securi y codes. Thl projectvill provide for construction and equipment of 5,500 m ofstorage, packing and shipment space, garage and workshop,handling and packing equipment, and two five-ton trucks fordistribution. The project will also provide for the localtraining of mid-level technicians and 5 a/= of foreign experts.

(c) Foru lotion The formulation of 46 basic drugs will be splitbetween industry and the UA. Formulation of all antibiotics,which involves more sophisticated procedures and representsthe major investments, is expected to be done by the privateindustry under contracts for toll manufacturing on the basisof costs plus an agreed-upon profit. Contracting for tollformulation, however, will not be considered part of the project.The rest of basic drugs such as tablets, syrups. ointments,

- 29 -

solutions, and suppositories, will be formulated by theupgraded formulation unit of the UAM. To this effect, theprojeqt vill provide for construction and equipment of a800 m formulation laboratory, a small galenic controllaboratory, a power plant and initial ingredients and suppliesfor the first year of operation of the formulation and packagingunits. The project will provide for machinery, laboratoryequipment, air conditioning and ventilation equipment. Theproject will also finance 18 fellowship/months for overseastraining in formulation as well as 6 l/i of foreign experts.

(d) Packauin. MOPE uses small quantities of sophisticated drugswhich are imported and distributed to hospitals already packaged.It uses large quantities of some 120 generic drugs purchasedand distributed under hospital packaging. Finally, the primaryhealth care services use about 100 drugs which are dispensedto patients and therefore must be safely and efficientlypackaged. The project will enable HOPE to purchase drugsin bulk and package them locally; it will also explore newforms of packaging -- color-coded courses of treatment,instructions understandable to illiterates, notices in Frenchand Arabic, coupled with IEC materials. The project willprovide for the construction of a 1,200 i packaging unit,and packaging and labeling materials and equipment. It willprovide for 6 fellowship/u for three key staff and 5 consultant/months of foreign experts for the improvement and continuousadjustment of packaging. At negotiations, MOPH has submittedthe preliminary drawings and engineering studies for the UANand the corresponding equipment list, which were approvedby the Bank.

2.27 Summarv of Technical Assistance and Fellow - -s. The projectwill provide for architect fees as vell as a total of 340 man/monthsof technical assistance and 248 man/months of fellovships:

(a) 222 consultanttmonths by local experts in the following areas:health planning; preparation of the extension of basic healthservices; management of MOPH, health services monitoring;health economics; hospital management; pharmaceutical managementand inventories.

(b) 65 consultant/months by foreign experts in management, operationalresearch, health economics, hospital management, pharmaceuticalmanagement, control of stocks, industrial pharmacy and drugpackaging.

(c) 150 man/months of post-graduate courses abroad in health planning,health economics, health administration, research managementand methodology, business administration, formulation, industrialpharmacy and marketing.

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NOPE way use WHO's assistance in the implementation of technical assistanceand the fellowship programs. The detail and timetable of the technicalassistance and fellowships are shown in Annex 1.4. All technical assistanceand fellowships financed by the project will be administered by thePIU.

III. PROJECT COST AND FINANCING

Cost of the Proiect

3.01 The total project cost is estimated at US$47.6 million includingtaxes (US$7.1 million). The foreign exchange component of the projectwill amount to about US$24.3 million. The breakdown of costs by projectcomponent is shown below:

Tble i: Pfoject COst SM

01u31 low) S "0o0) z mel

lowal Foreni Tota locl ram*. Total l_ba Costa

adie Smith Uexvim 18,3.4 10.0873.0 219,259A 12,50.2 10,651.9 3,153.1 16 70J. MlQ 7,435.8 8,58.7 16,08.5 785.2 906.S 1,691.5 54 5C. MaiDa I ad : Capcit 4,317.5 10,36L8 14,686.3 455.9 1,09.9 1,550.8 n 5D. DM awly 9tm 23,073.1 41,755.9 6X,82.0 2,436A 4,4093 6,845.7 64 21

TO N 153,212.8 161,51D3 314,7.1 16,178. 17,062.3 33,21.1 51 100lyicl Ccitim 11,757.8 14,628.5 26,36.3 1,241.6 1,544J 2,786.3 55 8Prim Ciatkamaw 46,061.7 43,7813 89,846.1 4,.0 4,623.5 9,487A 49. 29

TOaUl P3U o 006 21,03.3 219,93.2 41,02.5 22,34.3 ,230.5 45,514.8 51 137m _- m

Pzdo,r forlqieaim Bayus 10,O0.0 1,000.0 21,000.0 1,00.0 1,1.0 2,10.0

Tbtal PM 0065witb Pivism Z1,2.3 230,93.2 452,05.5 2,34.3 24,30.5 4,4.8

3.02 The base cost estimates for the project are as of April 15,1985. The estimates for zivil vorks are based on preliminary drawingsof project-related constructions and on the 1985 unit cost of constructionfor similar works using economical construction methods. The cost estimatesfor equipment, furniture, and drugs are based on agreed lists of itemsto be procured and on the cost of procuring similar items in 1984. Theestimated cost of fellowships, including travel, averages about US$1,780per man/month. Detailed cost tables are presented in Annex I.

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3.03 The total cost estimate includes 102 physical contingenciesfor civil works, furniture, equipment, drugs and medical supplies.Price contingencies are estimated over the project implementation period,for all expenditure categories, as follows:

1985/86 1986/87 1987/88 1988/89 1989/90Local costs .10 .07 .06 .06 .06Foreign costs .07 .08 .08 .08 .08

In the absence of a sector profile and because the average disbursementperiod for Morocco is 8 and a half years, as a hedge against possibledelays in the proposed five-year implementation, a contingency forimplementation delays for an amount of US$2.1 million has been addedto the project cost. This contingency is derived from a direct estimateof two additional years for the completion of the project.

3.04 The estimated foreign exchange component of the project isestimated at US$24.3 million. The breakdown of foreign exchange bycategories of expenditure is as follows: civil works, 40z; furniture,55z; equipment, 802; vehicles, 70S; drugs, 60X; fuel. 802; foreign expertservices, 902; fellowships, OOZ; and local training, 302.

3.05 The loan will also finance on a declining basis the incrementaloperating costs of the health services (excluding hospitals) in thethree provinces over a five-year period in respect to: a) the basicdrugs; b) transport costs and statutory travel allowances for staff(VDNS, itinerant nurses, mobile teams and supervisors); fuel and vehiclemaintenance.

3.06 Incremental Recurrent Costs. Incremental recurrent costsgenerated by the project are estimated at US$9.9 million including contin-gencies and US$1.6 million in taxes. This includes net of tax salaries(US$2.9 million), an improved supply of drugs and medical supplies (US$3.1million), as well as sanitation supplies (US$0.2 million), office supplies(US$0.3 million), fuel, travel costs and subsistance (US$1.8 million)to improve the mobility of outreach personnel. Incremental operatingcosts of the project will increase from US$0.9 million during the firstyear of the project to US$2.8 million in the fifth year and are expectedto level off thereafter. The increase in incremental operating costsoccurs because in recent years, MOPH's actual resources at the primaryhealth level declined in real terms, resulting in a decline in coverageand deterioration in the quality of services. Consequently, outreachservices have to be funded to a minimum level to restore the credibilityof the system, at the same time as the project eztends coverage to largersegments of rural low-income populations. In the first year, incrementaloperating costs will represent 0.9Z of MOPR's 1984 recurrent budget;this ratio increases to 2.9Z by the fifth year. Such low percentageof NOPE's operating budget underscores the replicability of the project.The feasibility of future expansion of the proposed PBC system is furtherenhanced by expected savings in the cost of drugs, improved management

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of hospitals and cost recovery uechanisms that vill be explored by thestudy on financing of the health sector.

Proiect Financing

3.07 The proposed IBRD loan of US$28.4 million vill finance 70Xof total project costs net of taxes, including a PPF of US$75,000 thatwill be refinanced under the loan. The GON vill provide the equivalentof US$12.1 million to finance the local costs, equal to about 302 ofthe total project cost net of taxes, plus US$7.1 million in taxes andduties. The GON has included in the 1984-85 budget a total of DR 72million for the initiation of the project. The financing plan, brokendown by category of expenditures, is ohown below:

Table 2: Finwcing PIn

~~~~::- . : *Bgediture Tota*01Category ::(US$ wil) (Zfinmcuig): (E$ nil) (Ifinsnig): (U$ nil)

1. Civil Wlks :: 4.4 30: 10.2 70: 14.6

2-. 3W#pwt, Maeialis1,::::Frai±e G Vehicls:: 2.4 20': 9.6 80: 12.0

3. Traing Seuinars :: 0 0: 0.3 100: 0.3

4. Tecbmical Assistance::& Feldships :: 0 0: 2.8 100: 2.8

5.P0PA :: 0 0: 0.1 100: 0.1

6. lncrin±a:ReatwretnCosts :: 1.8 32: 3.9 68: 5.7

7. Salarias :: 2.9 100: 0 0: 2.9

8.Tmes :: 7.1 100: 0 0: 7.1

9. Provisi fi ::flTZletatizm Delas:: 0.6 30 : 1.5 70 : 2.1

IUAL :: 19.2 : 28.4 : 47.6

* All amomts for It.X 1 thzu 7 are net of tun.** 0.1 is the roxded figue for the MF of S$5,OW.

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IV. PROJECT ORGANIZATION AND IMPLEMENTATION

Ornanization

4.01 Overall responsibility for the project will rest with NOPEthrough its Direction des Affaires Techniques (DAT). As shown in MOPH'sorganizational chart in Annex R.1, all units taking part in projectimplementation are under this Directorate. The DAT commands tb.I necessarylines of authority for project implementation. It will: a) supervisethe implementation of the Health Services component, through its norualtechnical authority, over the Medical Directorate in each of the threeprovinces; b) implement through its DICP the Planning and Studies sub-components, and in coordination with the DAA, the MDPE Management sub-component; c) implement, through its Population Division, the Trainingand IEC component; d) and implement, through its UAf, the Drug Supplycomponent. NOPE has designated the Director of Technical Affairs asthe "sous-ordonnateur" giving him full authority to comit all projectresources and authorize payments accordingly.

4.02 Within the DAT and under the direct supervision of the Directorof Technical Affairs, a Project Implementation Unit (PIU) has been createdby ministerial decision No. 2669 DT/206 dated December 4, 1984, establishingits terms of reference. The PIU has been given overall responsibilityto conduct all project-related procurement, disbursement and accountingoperations. The decree appointed the Project Coordinator, as vell asfive professionals - an administrator, a medical doctor, an economist,and two bead supervisors of health services. All PI-appointed professionalstaff are well-qualified and have actively participated in the preparationof the project. An experienced architect will be assigned to the PI.In addition, four secretarial and support staff have been assigned tothe PIU. The Sinister has also designated the interim director of theUAE to be developed under the project. All MOPE units will report tothe PIU on matters related to the project. At negotiations, assurancesvere obtained that the Borrower will continue to maintain the PTU vithorganization responsibilities, staff, and terms of reference satisfactoryto the Bank over the duration of the project.

4.03 In the three provinces, the project vill be implemented bythe provincial Medical Directorates of Agadir and Settat as implemen-tation in the recently created Province of Taroudant will be supervisedthrough the experienced staff of Agadir Medical Directorate. Underthe overall responsibility of the PIU architect, civil works will besupervised by MOPE's construction units in Rabat, Agadir and Settat;each one of these units will be reinforced with a civil engineer anda civil work supervisor who vill work full-time on the project.

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Prcu remeat

4.04 Laws and regulations regarding local procureueut proceduresand practices in Morocco have been revieved in the Bank in order toreach a judgement as to whether local procedures are acceptable forBank-financed contracts. The findings of that review were discussedwith the Moroccan authorities and agreements were obtained duringnegotiations regarding any changes needed to make the proceduresacceptable to the Bank. Procureseut arrangements are sumarized inthe table below.

Table 3: Pzruaun S-Mi:Y(in MSs umiica)

mm I NA. I Ct

I I

cbil un 1 - 26 2.0 - I 14.6(8.8) (.) I O1)

I II5.3 0.6 1* - 1 7.2

(4.2) (03) (1.1) 1 (5.8)

-m;I 0.5 0. 0.* - I 1A. 0.4) (03) (0A) 1 (1.1)

Ibtnia& I 2.1 - - - I Li:1jW I .7) I (1.7)

Vbic1m I 1.3 - - - I 1.3

I (1.0) ~~I (1.0)

Tzmi.i~ I _ _ - 0.3 1 0.3S;IID 1 (03) 1 (0.3)

-I I-T.imiclksiatm I - - - 28 1 2.8_lWindds 1 (23) 1 (LS)

1inoa1 1 1.9 1.0 - 23 1 5.7bin,nz = .t. 1 (1.3) (0.7) (1.9) 1 (3.9)

= ~~~I I-sIari_ I - - - 2.9 1 L9

I (0) I (0)Il I

ION I - - - 7.1 1 7.1I (0) I (0)

?ruwiasi. f I 2.1 I 2.Tl_int*im ~1y1(.5) I (1.5)

1W I 0.11 0.1I (0.1) I (0.1)I

1XL I 11.1 14.6 3.8 181 1 47.6I (U6) (103) (2.9) (6.) I (254)

*1551.3 ilm Mt of tc in G*tiPm - Iuini- M ttobe i m.i Jkm . s1W; i n.500,00 in .pi a am .ut to be I mI mh pzadm df-Um.:1f i,^.

Note: Figures in parenthesis are the approxiiate respective amountsfinanced by the Bank.

- 35 -

4.05 Civil Wgrki. Most of the civil works will be located in remoteareas and will be too samll to attract foreign contractors. Consequently,the amount of US$12.6 million net of tazes will be avarded on the basisof competitive bidding advertised locally, in accordance with proceduresacceptable to the Bank. MOPE's central construction unit will preparestandard bidding documents acceptable to the Bank for each type ofconstruction. Civil works, up to an aggregate cost of Vs$2.0 millionequivalent, for the remodeling works or the construction of sall healthfacilities in remote areas where no contractors could be found, mybe carried out by force account with Bank's prior approval.

4.06 Goods. The total cost of equipment, furniture, materials,supplies, vehicles and drugs, is estimated at US$14.9 million net oftazes, of which US$11.1 million will be procured through internationalcompetitive bidding in accordance with Bank guidelines. Qualifyingdomestic manufacturers vill be given a margin of preference of 151 orthe applicable import duty, whichever is lower. To the extent practicable,contracts will be grouped in bid packages of US$100,000 equivalent ormore, each. Equipment, furniture, materials and supplies for the healthfacilities, estimated to cost about US$1.3 million net of taxes, maybe procured through UNICEF. Items which cannot be grouped in packagesof more than US$100,000 but not exceeding in aggregate US$1.5 millionequivalent may be procured through competitive bidding, advertised locally,in accordance with procedures acceptable to the Bank. Contracts formiscellaneous goods amounting to US$15,000 equivalent or less, but notexceeding US$500,000 equivalent in total, may be procured through prudentshopping after obtaining at least three price quotations.

4.07 Services. The selection and appointment of consultants andtechnical assistance specialists (including architects) will be inaccordance with Bank guidelines.

4.08 Bank Review Requirements. Construction contracts in excessof US$200,000 equivalent and contracts for goods in excess of US$100,000equivalent will be subject to tbe Bank's prior review. Such contractswill comprise about 80X of the total estimated value of civil works,furniture, material, equipment and vehicles. Other contracts will besubject to Bank review after award. Terms of reference and conditionsof employment of consultants and advisers as vell as their qual-'ficationwill be satisfactory to the Bank. Assurances were obtained that a listof courses and candidates for the fellowship program will be submittedto the Bank for prior review.

Disbursement

4.09 The loan proceeds will be disbursed as follows (Annex J):

(a) civil works: 702;

- 36 -

(b) equipment, furniture, materials, supplies and vehicles: OOZof foreign expenditures; 100% of local expenditures (ex-factory);and 60Z of total expenditures for otber items procured locally;

(c) technical assistance, fellowships and training seminars:100x.

(d) incremental recurrent costs: 68%. Disbursements vill coverpayments from December 4, 1984, through the first year afterthe signature of the Loan Agreement up to a limit of US$0.3million, US$0.8 million for the second year, US$0.7 for thethird year, US$0.6 for the fourth yeer, and US$0.2 for thefifth year.

Retroactive financing up to a limit of US$2.0 million for all paymentsfor expenditures eligible for Bank financing, made on or after December 4,1984, date of the establishment of the Project Implementation Unit, willbe accepted. Disbursements for packaging materials and ingredientsunder the drug supply component vill be limited to a total of US$1.5million equivalent. The GON will fully document all disbursements fromthe loan amount except for: (i) civil works on force account, and (ii)expenditures for training which vill be made against certificates ofexpenditure. The documentation for these expenditures will be retainedby the GO) for audit and inspection by project review missions. Thedisbursement schedule is presented in Annex I. The present loan isexpected to be fully disbursed by December 31, 1991.

Accounts and Audits

4.10 During negotiations, assurances were obtained that NOPH willkeep separate accounts for all project-related expenditures, which willbe audited annually in accordance with appropriate auditing principlesby independent auditors satisfactory to the Bank. Copies of the auditedstatements will be provided to the Bank for review within six monthsof the end of the fiscal year. These reports will include an opinion(and comments as necessary) on the methods employed in compiling thestatement of expenditures, their accuracy, the relevance of supportingdocuments, elegibility for Bank financing, and the standard of record-keeping and internal controls related to the foregoing.

4.11 It is estimated that the present five-year project will becompleted by 1989, as shown in the implementation timetable in Annex1.3. HOPE's central staff in charge of the preparation of the projectwill be incorporated in the PIU and DICP's units concerned with theproject; implementation of many project activities will immediatelyfollow preparation. In order to keep the momentum, during the firstsemester of 1985, MOPH will continue or initiate four key project activities:

(a) first phases of the studies on the Financing of the Sectorand Hospital Management;

- 37 -

(b) training of key central and provincial staff;

(c) upgrading of existing facilities in Agadir, Settat and Taroudantprovinces; and

(d) preparation of the 1986-88 Health Development Plan.

To carry out these activities, MOPH will utilize funds allocated tothe project in the 1984-85 budget: DR 60 million for the first component,and DH 12 million for the fourth component.

Monitorint

4.12 Continuous monitoring and evaluation are essential to thefirst component of the project. The DICP will be responsible for monitoringimplementation in the three provinces. Such measurement viII cover:

(a) inputs: civil works and procurement, timeliness of refreshertraining, increase of drug supply, improvement of ISC support,quality of technical support at central and provincial levels.Monitoring of inputs vill be carried out by the PIU incollaboration with the three provincial directorates.

(b) outp_uts will be monitored through process indicators - activitiesperformed, coverage, utilization of services, drug utilization,referrals, indicators of quality and cost of services. Processindicators will be measured through health services monitoringcomplemented by operational research as described in AnnexesFKl and F.2.

(c) outcomes of the six core programs, detailed in Annex C, willbe periodically assessed through population, health and nutritionindicators against set targets. Baseline data will be collectedin the project by the end of 1985, mid-term evaluation willassess early trends by the end of 1988 but health status indicatorsare expected to show significant progress at final evaluation,by mid-1992. Specifically the project will focus on the followingtargets:

(1) Knowledge of modern contraceptive methods smong vomenwill increase from the present 632 of MYRA to 90% in1989.

(2) Contraceptive prevalence will increase to 362 in Agadir,38.5Z in Settat and 232 in Taroudant by 1989. Intermediatetargets for 1987 are shown in Annex C.

(3) Percentage of children receiving standard isamunizations-- coverage is expected to raise from present 36% to

- 38 -

60% in 1987 and 80% in 1989. The percentage of vomenreceiving tetanus toxoid during pregnancy vill rise fromthe present 5% of pregnancies to 55% by 1989.

(4) Coverage of prenatal clinics vill rise from present 5.4%to 35% by 1989. The percentage of supervised deliverieswill increase from the present 11Z to 55% by 1989; 80Zof high-risk pregnancies vill be delivered in uaternitiesby 1989.

(5) Infant mortality among rural population of the projectarea will decrease from 150 per 1,000 at to 80 per 11000by 1989. Maternal mortality among rural population ofthe project area will be reduced to under 250 per 100,000live births by 1989.

(6) Five specific causes of deaths, selected as tracers orindirect indicators of care - deaths under 5 years ofage due to diarrheal syndromes and acute respiratoryinfections; death by eclaupsia and rupture of the uterus;and deaths of tuberculosis for all ages and sexes --will be measured and monitored for progress.

(7) The supply of 46 basic drugs vill increase by 50X in1987, and by 150% in 1989. The utilization of basicdrugs -- prescription, dispensing and patient'scompliance - vill be monitored through operationalresearch in nine provinces during 1986, 1987 and 1988,as shown in the timetable in Annex F.2.

ReportinD and Evaluation

4.13 Overall monitoring, reporting and evaluation of the projectwill come under the responsibility of the PIU which will insure timelycollection of information needed for the preparation of semi-annualprogress reports and its submission to the Bank.

4.14 As head of the PIU, the Project Coordinator vill conduct amid-term evaluation of the project vhich will cover project componentsas vell as necessary adjustments of the PHC systems and conditions ofreplicability. By December 1987 the GOM expects to receive the mid-termevaluation report to decide on the extension of the PEC system to otherprovinces, possibly with Bank assistance. Assurances were obtainedduring negotiations that the Borrower vill prepare and furnish to theBank a mid-term evaluation report, including the findings and recomen-dations of the research mentioned in para. 2.14 (i), by December 31,1987, and implement such tecommendations as shall have been agreed withthe Bank.

- 39 -

V. PROJECT JUSTIFICATION MAD RISKS

Just if icat ion

5.01 In addition to br'nging direct benefits to 102 of Morocco'spopulation, the project will help the Government to organize the healthsector and introduce overdue policy changes. It will improve the healthstatus of a sizeable proportion of Morocco's poorest population, testan alternative to the present health care delivery system, and assistinstitution building in MOPH.

5.02 The deployment and operation of the reinforced and reorganizedbealth services in three provinces (total population 2.1 million) willyield the following tangible direct benefits:

(i) Pooulation: Improved faoily planning services and IEC willsignificantly increase contraceptive prevalence in three pre-domionatly rural provinces which include 10S of the Moroccanpopulation. Contraceptive prevalence is expected to risefrom present 242 of MMlA to 332 in 1989 and 372 in 1992.Hovever, the benefits expected in the project area, alreadysignificant by themselves, are only a step in the extensionof the family planning program. The experience gained inthe project area and other provinces covered by the VDHSprogram will facilitate the extension of the program to therest of the country over the next ten years when the nationalcontraceptive prevalence will reach 37Z in 1992, 40.52 in1996 and 432 in the year 2000. These contraceptive prevalencerates vould result in total fertility rates of 4.8 in 1989,4.6 in 1992, 4.4 in 1996 and about 4.3 in 2000. The crudebirth rates would accordingly decrease from 40 per 1,000 in1985 to 28 per 1,000 in 1996, and to approzimately 27 per1,000 in 2000. Assuming mortality and migration remainconstant, the total population of the country is projectedat just over 30 million by the year 2000.

(ii) Health: There will be a substantial improvement in healthconditions in three provinces. Mothers will be protectedby improved MCB services; infants and children will benefitfrom extended imiunization and control of diarrhea and acuterespiratory infections. Restored confidence in the healthservices will open the possibility of sustained preventivecare in the future, and introduction of cost recovery mechanism

(iii) Nutrition: Although only a limited improvement in nutritioncould be expected from tbis project, especially if droughtspersist, the most severe consequences of child malnutritionwill be alleviated and irreversible biological damsge prevented.

- 40 -

5.03 The testing of the new health system in the three provincesvill pave the way for further expansion of a more cost-effective approachwhich will eventually benefit the vbole population of Morocco.

5.04 Institution building in HOPR will lead to tangible resultsin terms of: a) better allocation of scarce resources; b) cost-containmentin hospitals; c) more efficient management of drugs; d) better trainingof paramedicals; and e) more cost-effective basic services. The projectwill equip NOPH to measure its own performance and devise oetter approachesto healtb problems. Policy vill be based on better planniing, researchand evaluation, and changes of policy vill be more effectively implemented.Institution building of HOPH will bring about a coherent health plan,including the coordinated development of public services, Social Securityand the private sector; the gains obtained will greatly surpass theimmediate benefits brought about by the improved internal managementof MOPH.

Risks

5.05 The project is subject to the risks attendant on a first projectin the sector. The technical risks inberent to the deployment and operationof a new health system have been reduced insofar that the technicalinnovations have been well-tested, and central and provincial healthteams have been reinforced with competent staff. Riscs have been furtherreduced by early project start-up to be financed retroactively.

5.06 During project preparation, the risk of delays in projectimplementation has been reduced in the following ways: a) by strengtheningHOPH coordination with the Ministries of Finance, Planning and EconomicAffairs which led to a consensus on the proposed implementation scheduleand the corresponding annual budget allocations; b) by establishinga strong PIU and securing support from other MOPP branches; and c) byseeking at negotiations assurances on deadlines for key operations,many of which are already being implemented. In addition, the strongpolitical comituent and support for the project in the three provincesand the Government's interest for institution-building in MOPE fromthe outset of the project are likely to keep implementation on schedule.

5.07 The project vas designed to minimize incremental operatingcosts, especially during 1985 and 1986, the first two years of operation.The project vill be included in the forthcoming Development Plans of1986-88 and 1989-93, and the corresponding budgetary allocations willbe individualized in the annual operating budget (Programe d'Emploi)of MOPE.

- 41 -

VI. AGREEMENTS AND RECOMMENDATIONS

6.01 Before negotiations, MOPH has submitted the following documentsvhich met Bank approval:

(a) The revised architectural designs for dispensaries, healthcenters Types 1, 2, and 3; preliminary dravings for thebospitals of Taliouine and Ouled Teima, and drawings forupgrading the hospital. of Taroudant, Benabmed and Ait Baha,as well as the revised corresponding equipment lists (para. 2.08);

(b) the preliminary drawings and engineering studies for the UAMand the corresponding equipment lists (para. 2.26 (d)).

6.02 At negotiations, assurances were obtained that the BorrowerVill:

(a) ensure that DICP at all times continues to carry its operationwith full-time qualified and experienced staff in adequatenumbers (para. 2.11);

(b) prepare and furnish to the Bank, by December 31, 1986, theaction plan for the improvement of MOPH's management, andwill carry out such action plan as shall have been agreedwith the Bank (par. 2.13);

Ic) appoint by December 31, 1985, an interministerial steeringcomittee for the coordination of the Study on the Financingof the Sector; final results and recomendations will befurnished to and discussed with the Bank by December 31, 1988.(para. 2.14 (ii));

(d) furnish to and discuss with the Bank by Deceuber 31, 1988,the findings and recomendations of the Study on HospitalManagement, and will implement such recomendations as shallhave been agreed with the Bank (para. 2.14 (iii));

(e) prepare each year, and submit to the Bank for coments befor-December 31, the following year's detailed program for theproduction and utilization of IEC materials (para. 2.22);

(f) establish and uaintain the UAN with terms of reference andstaff acceptable to the Bank to be responsible for all stepsof the drug supply process, and ensure througb individualizedannual budgetary allocations that the UAM is provided witbsufficient funds for its drug supply operation over the durationof the project (para. 2.25);

- 42 -

(g) continue to maintain the PIU with organization responsibilities.staff, and terms of reference satisfactory to the Bank (para. 4.02);

(h) submit for Bank approval the terms of reference of consultantsand lists of courses and candidates for the fellowship program(para. 4.08);

(i) have the project accounts audited annually in accordance withappropriate auditing principles by independent auditors acceptableto the Blak, and furnish to the Bank certified copies oa: theproject audit reports within six months of the end of eachfiscal year (para. 4.10);

(j) furnish the aid-term evaluation report, including the findingsand recomendations of the study mentioned in pars. 2.14(i),to the Bank by December 31, 1987, and implement such recommen-dations as shall have been agreed with the Bank (para. 4.14).

Condition of Disbursement

6.03 No disbursements will be made against the drug supply componentuntil the Government has establisbed the UAN.

6.04 The above assurances having been obtained, the project issuitable for a Bank loan of US$28.4 million equivalent to the Kingdomof Morocco for a term of 20 years including five years of grace.

- 43 -

ANNEXES

-44 Annex ATable A.1

FAMI LY AN=I - CMInhCEPTIVE PREV&LI

:CmtraceptiveDistributioms Prevalence Rate CZ)

ByYears 1978 12 (1)1979 _1980 19 (2)1981 21 (3)1982 -

: 1983 25.5 (4)

ByUrban/ Urbn 42.5Rural Rural 15.2

ByAge 19-24 yers 18.6Group 25-34 " 30.1

_35-4 " 28.545-59 17.3

By Imber : 0 4.0of Liig : 1 19.0QCildrer.: 2 26.3

3 31.0: 4 30.0: 5 and over 30.9

By Metod : Pills 16.8:IUD 2.0

Tubal Liation 1.7Co:dm 0.7

Total Modern Methods 21.2

Traditional Mhtbods 4.3Total All Nethods 25.5

Souces: (1) DS&I estinates based on statistical data.(2) Natia survey an fertility and family planirg.(3) 1SD appraisal mission estimtes.(4) National survey an contraceptive prevalence.

Annex ATable A.2

IWAL7H 1EVEUW PFJE

NMRMONL ffATUS - DEVTIWS FROM S AMARDS, Er AGE, EE IN 01AND MM IN KG (1970)

untry Urban Rural

Age in Height Weight Height Weight eigt Weightlith (CM) (kg) (an) (kg) (cm) (kg)

Birth 0.7 0.3 1.7 0.4 0.6 0.26 -1.6 -0.6 -0.3 -0.5 -2.3 -0.812 -3.2 -1.2 -2.2 -0.3 -3.8 -0,718 -1.8 -1.8 -1.9 -1.7 -3.6 -1.924 -7.3 -1.9 -6.5 -1.6 -7.7 -2.130 -8.1 -1.9 -6.9 -1.5 -8.7 -2.236 - -1.8 - -1.6 - -2.042 -7.8 -1.9 -7.7 -1.9 -7.9 -2.048 -6.9 -1.8 -6.6 -1.7 -7.5 -2.2

Source: Ministere de la Sante Publique, 'Vliquete Ntionale sur l'Etatde Nutrition des Enfants de Nbins de 4 Ans, 1971",reported in Bulletin de la Sante Publique, Rabat, 1973.

NUTIONAL MA= AS PHME2I OF Dn XRSW1

Calories IProtein ICalciun I Irmn I Vit. A I Vit. Bi I Vit. B2 I Vit. C I NiacinX ir) (g 6) ( Ng) ( IU*tirg) ( Ng) (mg 6E!1 )

I I I I l I URnaN 95.4 I 104.5 I 59.0 1 105.6 1 106.4 1 108.6 1 131.0 1 105.8 1 -HUamL 112.7 1 125.0 1 59.6 1 147.2 1 64.8 1 196.0 1 46.2 1 53.0 1 -nPAL 106.9 I 118.3 I 59.2 1 132.4 78.9 1 173.9 1 30.5 1 70.3 i 102.6

I I I I EI II

* International Unit

Sburce: Secretariat d'Etat au Plan et au Developpeneat Regional,La conscummtimn et les depenses des nrages au Maroc, 19 0-71, Vol. IV.

[ S-N9Se@S f¢ S. E iiN~~~~ ii----- - - - - - - -------------- ----

0 0 0 0 - N ~F W 0% 0 8 - w E

.~~~~~~~~~ S 50 6 u 0sSSo "INId~~~~~~~~~~~in |

- - - - - - - - - - -- -- - - - - - - - - - - - - - - - - - - -- - ~ ~ ~ ~ ~ ~ ~ ~ ~ ~~:>

- 47 -Annex ATable A,4

D FM PRME ME SEV=MDrfVS OF t OI.NIt IT SYNI OR uP OF DISEASE - 1983

Nuber Mild & Treated Severe & TrestedSyndrcu or Diseae of Cases % by Paruedical by Medica1 Staff

Staff (Z) (Z)

A. 0 to 5 Yeas of Age

1. Diahea amd/or vaititg 4,523 39.2 81.6 18.42. Other disorders of digestive system 582 5.0 77.1 22.93. Acute respiratory infertions 943 8.2 78.6 21.44. Skm infections 650 5.6 92.3 7.75. ?Im-infectious skin disorders 1,061 9.2 n.o 29.06. Fervos system disorders 202 1.7 90.0 10.07. Fever, unmpecific origin 2,021 17.5 88.6 11.48. Urinary disonders 94 0.8 100.0 0.09. Trumsnsad burns 456 4.0 86.6 13.4

10. Eye disorders 192 1.6 89.0 11.011. Oral cavity disorders 111 1.0 100.0 0.012. Other syndruzes 710 6.2 75.5 24.5

70TAL 11,545 100.0 85.8 14.2

B. 5 Years and Over

1. Diarrhea and/or vcmitiig 2,674 14.4 59.4 40.62. Otber gastro-inteatinal disorders 2,179 11.7 59.7 40.33. Acute respiratory infections 1,306 7.0 61.2 38.84. Skin infectimns 368 1.9 84.2 15.85. Noo-infectious dkin disorder 2,048 11.0 57.6 42.46. Nervous systen disorders 1,080 5.8 86.1 13.97. Fever, unipecific origin 2,782 15.0 66.1 33.98. Uriamry disorders 907 4.9 44.1 55.99. Gynecologic disorders 743 4.0 50.0 50.0

10. Disorders related to prepnxy 65 0.3 15.4 84.611. Truans and burms 1,127 6.1 71.0 29.012. Eye disorders 340 1.8 78.8 21.213. Oral cavity and dental diworders 711 3.8 36.5 63.514. Other syKriw 2,233 12.0 69.0 31.0

IDTAL 18,563 100.0 59.9 40.1

Source: Adapted fran "Sumple Survey of PathoDog", Project Prsparatimn, Prow. of Apadir,Ministry of Pbblic Health, 1984.

5IPWJPI/QB

- 48 -Annex ATable A. 5

HFAEHDI EYEOUEN PFD=

Nk1RNOU RESOURCES IN PTJKI HffiLTH SBCM1TR(1976 - 1983)

I TYOEF PES?B I 1976 1 1977 1 1978 1 1979 1 1980 1 1981 1982 1 1983 1

IMedical/Direetors I 441 461 461 46S 461 461 461 461

I hzmincist/Directors I 4 1 4 1 1 1 1 1 2 1 41 4 1 4 1

IDouctors 1 710! 780! 780! 780! 7801 7801 780! 1,0501

IPhazscist 1 8J7 87! 601 86 86! 871 87 1 wi

IDstists I 20 20! 201 20! 20! 20 21 301

IVeterinariAms 11 1 1 1 11 1 11 11I I I I I I I I I I

Architect/Engineers 1 17! 19! 191 19! 191 191 19! 31!

IMedical Faculty 1 81 8! 91 9 10! 9! 9 271

Certifid Nurses I 1,946 I 2,199 I 2,799 1 3,215 1 3,913 1 4,725 1 5,083 1 5,589!

I Atxiliary Nirses I 9,570 1 10,022 1 10,890 1 11,647 I 13,188 1 14,414 1 15,706 16,590

Aministrators 1 236 274! 2751 3191 318! 348! 350 438

I Skilled Workers I 1,581 I 1,785 I 2,462 1 3,100 1 2,929 1 3,346 1 3,432 1 4,016 I

I Intes 1 1,160 I 1,481 I 1,678 1 2,978 1 2,980 1 2,919 1 3,247 1 3,247 I

IResidents 1 417 636! 7651 931 931 1,235 1,475 1,475I ~ ~~~I I 1 1 1 1 1 1

I Tpories 1 5,631 1 5,816 I 5,815 1 5,911 I 6,017 I 5,733 1 5,769 1 6,069 1

1Otber 1 310 345 1 474 1 557 1 539 1 655 ! 717 787!

1~~~~~ 1. 1 1 1 1 1 1I

TAE;L 1 21,742 I 23,523 I 26,094 1 29,620 D 31,779 34,341 1 36,745 I 39,487

Source: "Health Personnel Management", Revue Marocaine Med. Sante, 1983

- 49 - Annex A.6

Page 1 of 2

MOROCCOHEALTH DEVELOPMENT PROJECTHeolth Manpower Educadon

Educaibon Scheme and Cokgode of Peluonnel

J3 (Spud) (5)

RadancV 2_ ~~~~~~~~~~~~~DoeRmnh

_ __ t ;------------- -CM swwico F'~~~~~~~~~~~~Ocici

ffE~~AE

unwf 3 ffWN_ , D _ E--- S~r SDE(2)

2 M -

2rndCvdg 6 kO

1atcvei 3ESic5Non 5.

1. AMents de Sant6 Bre'vetfis (ASB) or Basic Nurses

After four years of secondary education, applicants are recruitedon the payroll of the civil service for two years of basic trainingin hospital nursing and public health nursing. Tventy-eight schoolsin as many provinces graduate a total of 2,000 basic nurses annually.Because of budgetary li-mitations, admissions were drastically reducedto 900 in 1983. The 16,000 basic nurses active in the country are evenlydistributed between hospitals and peripheral health services; they providethe basic staffing of the services. Only 10% of the ASBs are female.While basic nurses are well suited for hospital work, they prove tobe less cost-effective in peripheral services. Because ASBs bave adoptedurban values during their four years of secondary education, they havedifficulties in adapting to isolated rural areas, particularly to thelow-prestige itinerance. All paramedicals must serve in the MOPH fora number of years before they could go to the private sector. manyASBs, however, choose to complete secondary education by correspondenceand apply to the School of Certified Nurses or quit the sector aftertheir service obligations are fulfilled.

- 50 - Annex A.6Page 2 of 2

2. Agents de Sant6 Divl1m6s d'Etat (ASDE) or Certified Nurses

Recruited after the completion of secondary education anda qualifying examination, students undergo two years of training tobecome either Certified Nurses or Specialized Nurses (in clinicallsurgical,psychiatric, pediatric nursing, etc.) or Technicians (in laboratory,dentistry, X-ray, anaesthetisiology, rehabilitation, sanitation, etc.).The ASDE level offers different options. Eight schools of nursing andten schools of technicians graduate an average of 400 certified nursesand 500 technicians each year. The 6,000 ASDEs are the backbone ofthe services, their qualifications are well-appreciated in the publicand private sector. Only 60% of the posts budgeted for ASDEs in theNOPH are presently filled with qualified incumbents, a situation thatwill be resolved by 1989. The percentage of female ASDEs, badly neededfor MCH and family planning services, increases steadily and reached33Z in 1983.

3. Adioints de Sante DiPl6m6s d'Etat SDecialistes (ASDES), betterknown as 'Cadristes"

After serving in the health services, the most capable ASDEsare proposed for two additional years of higher education in management,.training or research at the Ecole des Cadres in the Rabat College ofPublic Health. The cadristes form an elite corps whose quality andperformance are well recognized and are in high demand for key positionsin the services.

4. Medical doctors are trained according to European standards andfollowing European curriculae in the two medical schools of Rabat andCasablanca. After five years of training, the medical student undergoesone year of internship in hospitals. All graduates in medicine, dentistryand pharmacy from Morocco or abroad must serve one year of civil services("Civilistes") in the MOPH.

5. Specialists after internship and civil service about 35% of physiciansundertake 2 to 5 years of residency to become specialists. All themajor specialties are now taken in Morocco and only few sub-specialtiesrequire training abroad.

P - - - - - - - - - - - - -- - - -

* - - - - - - - - - - - - - - - - - - - -- - - -VP

I- - gjm-I

- - - - -- - - - -

to VI _ g > W -V

L-b ~ ~ -

- - - - - - - ---- -- -- o -_

w -% -%

o 0 O~~~~~~0 Ui~~~~~J 1~~.1 1 U

------------------------ r---6 __ _% w __s- f

V ___ - -W

-52- *6un A

tabn.S A.3

hALtS S3YSLOPUUUY 110480!T

Capacity and Utiltinatien Idicatera of Osupitalebv PrevL:a- - 1932

............... .... a..............................__.........._._._.-....................._.,......_

Total Average AverageiTotel PataiAt Occpeancy Average Lengtb of Saily

Province :z Bad* Aduiesiena De:' late Occupancy stay Aduiteiet* ---- __.-- ..... __ .. fl.U.SSU.flSUS.fl.l......__..... _

Agadir : 1 339 35.665 353.337 69.3 969.6 9.9 97.7

Al-ocacima s: 349 8.095 66.376 52.1 181.9 8.2 22.2

Asilal us 154 2.641 28.786 47.7 73.4 16.1 7.2

seni melle s : 333 12.133 95.137 63.1 260.1 7.3 33.2

3am Ulinan a: 1? 417 3.467 50.0 9.5 8.3 1.1

Deulnane :: 40 3$6 5.172 35.4 14.-: 6 2.4

Cbsu :: 55 1.023 6.530 32.6 13.0 6.6 2.3

Kl-Jdida :: 520 9145 135.5384 71.4 371.5 14.8 25.1

11-Ide1a a: 187 4.521 50.662 74.5 139.3 11.3 12.4

Krrebidi-a : 415 9.814 113.736 75.1 311.6 11.5 27.1

-eeeo-ir-a : 367 5.249 64.747 46.3 177.4 12.3 14.4

o mra i: 15 57 239 4.4 0.7 4.2 0.2

Fee :: 1.529 25.050 343.683 62.5 955.3 13.5 70.3

Fiig :: 49 643 6.925 27.5 13.5 7.7 1.3

Kenitra :: 97 19.637 184.824 56.5 506.4 9.4 53.9

Ihenimet : 269 7.409 47.331 48.2 129.7 6.3 20.5

Ibheifr a: 228 8.5B0 54.829 65.9 150.2 G.4 23.5

heuribtga 79 4.190 15,596 54.1 42.7 42.7 11.5

Laayse a: 114 3.111 17.155 41.2 47.0 5.5 3.5

Harraek-c a: 1.785 29.170 475.121 7:.4 1.301.7 16.3 79.9

Maek :: 1.565 21.987 352,811 61.3 966.6 16 60.2

Nader a: 317 10.340 U3.255 72.0 228.1 3.1 23.3

uareanate a: 437 6.912 75.474 42.5 206.3 10.9 13.9

Ojda :: 960 23,198 213.302 60.9 584.4 9.2 63.6

Owed adeb : 4 40 912 4.214 23.9 11.5 4.6 2.5

afti :: 616 14.363 163.983 72.8 449.3 11.4 39.4

3attat a: 2.664 3.970 455.980 50.0 1.331.0 54.1 24.6

Tanger :: 615 14.114 164.556 72.2 444.0 11.7 38.7

Tan-Tan : 92 2.315 15.184 45.2 41.6 5.4 7.7

taonnate :: 130 4.929 31.149 47.4 35.3 6.3 13.5

Tatt :: 25 602 4.527 49.6 12.4 7.5 1.6

ane a: 382 3.335 80.213 57.5 219.3 9 24.3

Tetouan : 1.293 17.673 299.743 63.5 321.2 17 48.4

tignit :: 413 1.315 71.252 43.7 195.2 9.7 20

Cecblhanca 3.5283 63,13 786.714 61.1 2.155.4 12.3 174.3

tRbot-Bale :: 2.837 36.305 370.984 32.7 2.336.3 10.1 236.5

tOtAL :: 24.913 481.539 5,774,334 63.5 15.320.2 12.- _f..... ---- - _ -, .__ , M.

* _ *-_ _ __ .. ........ .…

- 53 -Annex ATable A.9

orsa o ur ms uionw CIlAMS u gm inAL g m1970-19

Ou0Um Dkzb)

::o PM 3A1 ::eaL ::

:: M::W :~~~:1 3: UL: :UE :U: : : :~: :U:: ,T SUA=: - : BM E : ; D : : -L -:.L: Z : 2 :: . (2) (2 :(Z

1970 :: 216: 55.2: 44.8 : 21: 37:: 2,719: 1,133 : 3,852:: 7.9: 1.9 : 6.21971 :: 217: 55.6: 44. : 14 : 231:: 2,97: 1395 : 4,34 :: 7.4 : 1.0 : 5.31972 :: 223: 55.8: 442 : 30 : 23:: 3,146: 1,609 : 4,754:: 7.1: 1.9: 5.31973:: 237: 57.8: 42.2 : 83 : 319:: 3,513: 2,2 : 5,751:: 6.7 : 3.7 : 5.51974:: 28: 63.1: 36.9: 41: 32B:: 6,123: 3337.: 9,450:: 4.7: 1.2: 3.51975:: 331: 63.1: 36.9 : 105 : 436:: 8,869: 68 : 15,137:: 3.7 : 1.7 : 2.91976:: 368 : 60.5 : 39.5 : 2 : 569:: 8,213: 9,4: 18,077:: 4.5 : LI : 3.11977:: 407 : 59.1: 40.9 : 195 : 6:: 8,86: U,744 : 2,630:: 4.6 : 1.7 : L91978 :: 49 : 62.7 : 37.3 : 147 : 646:: 9,468: 8,1 : 17,597:: 5.2 : 1.6 : 3.71979 :: 540: 63.7 : 36.3 : U9 : 659:: 10.622: 8,736 : 19,358:: 5.1 : 1.4 : 3.4196D :: 630 : 673 : 32.7 : 129 : 759 12,635: 8,42 : 21,062:: 5.0 : 1.5 : 3.6196 :: 701 : 67J : 32.2 : 238 : 939:: 15,357: 9,997 : 25,:: 4.6 : 2A : 3.7192 :: 8O : 69.8 : 30.2 : 300 : 1,10:: 18,105: 16,806 : 34,911:: 44 : 1.8 : 3.2193 :: 95 : 70.5 : 29.5 : 244 : 1,149:: 20,140: 18,714 : 38,854:: 4.5 : 1.3 : 3.01964 :: 918: 74.3: 25.7: 139:1,057:: 19.26: 10,155:29,391:: 4.8: 1.4: 3.5

&m: Einisty of Public l1kb m 1unatry of Pmn

---------- :--- -. ------- -------- --------- -

I~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~I

:11 1 >z 1, z 1 1a

_ I II I I I _-

j~~~~Ii I II~~~~~IFI

| - -- -------- ---- --- ----- --- ---- W--- -- -

- ~~~~~1 - 9 tII- ---9 --- --- - -- __

_ _ b b b _ L b b ; b b "

$1-g ---- --------------------------------!---Si y , l I i! ; r lI,i [!I I I. [[[l[ll|

t~ h[S h I- C &. 6b_^ |""t. I[at v _ qu

- 55 -

Annex 5Page 1 of 3

MORwOCCO

HEALTH DRVCLOPSCWT PROJECT

DescriDtion and Baseline DatjProvincec of Azadir Taroudant and Settct

Suarv Descript ion

8gadir, Taroidant together with Ouarzazate are the southernmost densely populated provinces; further south lay the desertic andsparsely populated SaharaD provinces.

In 1983 the Government divided the large Agadir Province with1.2 million population in two smller provinces, Agadir and Taroudant.In addition, the new province of Taroudant now includes large areaspreviously belonging to Ouarzaate. Most statistical data availablestill lump the two provinces together, and the Government is in theprocess of separating the two data bases.

Province of Agadir

The province is now reduced to a coastal strip 200 km longand 50 km wide. The province is limited by the High Atlas range tothe north and the Anti-Atlas to the south. In between the coastal plainis crossed by the Oued ouse., the Oued Chtouka, and other minor seasonalrivers. The province has a population of 624,000 - 3S of the country'stotal population - ef which 58S live in rural areas. Over the pasteleven years, the population of Agadir city and its suburbs of Ineaganeincreased at a tremendous rate of 7.6Z. The presence of a modern city.totally reconstructed after the 1966 earthquake, oriented toward tourismand developing industries, sharply constrasta witb the semi-arid agriculturalback country. Three socio-economic groups coexist without much inter-penetration: the Berber population of the Atlas and Anti-Atlas livea subsistence economy in dispersed villages high in the mountain valleys,the cosmopolitan urban population of professionals, governoent employeesand industrial workers. *and finally the Arab-speaking farmers and migrantworkers of the central agricultural plains.

There Pre three hospitals with a total of 1,200 beds (or aratio of 1.9 beds per 1,000 population), 9 health centers and 66 urbanand rural dispensaries. There are 76 physicians - or 1.2 per 10,000population - evenly distributed between the public and private sector.As such, the province appears relatively well served, but in fact theconcentration of large hospitals in the city of Agadir masks the shortageof facilities in rural areas.

- 56 -

page 2 of 3

Province of Taroudiat

Taroudant is economically and socially the back country ofAgadir. It extends over a vast territory, 200 km from nortb to southand 250 km east to west. Higb mountain ranges and arid plateaus forecastingthe Saharan rift, occupy most of the land. The Souse Valley narrowsrapidly to the east and fades out in desertic sparsely populated areas.The sain road links Ouarzazate to Agadir with few transversal dirt roads.The province had a population of 582,000 in 1983 and the density islow - 11.6 per km2 Two semll cities, Taroudant (26.000 pop.) andOuled Teima (25,000 *pop.) make for most of urban population wbile 9O0live in rural areas. Arab-speaking population. mostly settled in thewest, represents only 20S of the total while different ethnic groupsof Berber origin occupy the sountsive and Zastern plateaus. Most ofthe rural population lives in subsistence economy

Taroudant has only one hospital with 280 beds operating inprecarious conditions, 7 health centers and 49 dispensaries. Thereare 23 physicians in the public sector and 9 in private practice. Assucb, the province is grossly underequipped with 0.48 beds per 1,000population and 0.5 pbysician per 10,000 population. The bealth statusof the population is poorly documented. Malnutrition is highly prevalent:a survey of children between 0 to 4 years of age in the Aoulouz districtshowed in 1983, 31.91 of children as moderately malnourisbed and 10.81as severely malnourished.

Province-of Settac

The province of Settat is located in the Central region witha population of 717,500 in 1983. 791 of which live in rural areas.Settat province is typically agricultural and is known as the granaryof the country. Flat or gently rolling terrains in the western two-thirdsof the territory change to less fertile plateaus in the eastern third.The climate is influenced by the Atlantic winds and precipitation allowsfor extensive dry-farming of wbeat. During the period 1971-1982, itsgeneral population growth rate has been below the national average ata rate of 1.8 (as compared to 3.1), urbanisation has been at a rateof 3.8 (as compared to 4.4 nationally) and rural population growth rateis 1.3 (as compared to 1.4 nationally). The rural ezodus in Settathas affected other neighboring provinces ratbhr than its own urban centerswhich, in turn, contributed to its low population and urban growth rates.Settat's population is economically and socially boogeneous. The vastmajority is of Arab origin. About 301 of the agricultural populationare small farmers farming their own plots wbile 701 are tenants or agriculturalworkers farming large properties. Insufficient rainfall in the pastfew years has adversely affected family income, and in a cereal-ricbprovince malnutrition is still prevalent. A nutrition survey of Settatprovince in 1982 sbow that, of 2,692 infants in the urban areas, 161are moderately malnourisbed, 7.51 are severely malnourisbed.

- 57 -

Annex BPage 3 of 3

There are three hospitals in the province: a 1,900-bedpsychiatric national hospital in Berrechid which serves the entire country,a 309-bed tuberculosis hospital in Benabmed also serving several provinces,a 200-bed general hospital in Settat, and finally 56 beds in two RuralHealth Centers. In spite of the apparent infrastructure, the provinceis underequipped with only 256 beds to serve a population of 717,500for a very low ratio of 0.35 bed per 1,000 population. There are 10health centers and 36 dispensaries with a ratio of one health centerfor 71,750 inhabitants and one dispensary per 19,930. The provinceof Settat had 53 physicians in 1983, or a ratio of 0.74 per 10,000population, of which 36Z practice in the private sector and 642 in thepublic sector.

- 58 - Annex BTable. B.

s0c0-aoAc ~aIhcsfCO AM PF AEA

CEaIACIfISII(; NH0 : PAGDM SEr:TO TANWM:

kear (2)* :- 712,550: 23,480: 9,750:

Popalatim density :(persam per km2) :: 29: 48: 71:

1umtainacs ares (% * :: - : 60: 30:

Tota population: :: 21,000,0D : 624,600 : 717,500 582,200- vral paim (Z) :: 57: 58: 79; 90- urbm pouation (Z) : 43: 42: 21: 10-w iin reproductive age (Z) :: 17 : 27 : 16.9: -

gax.tb~~~~~~~~Fbpdatiax grCh :rate (197182) :: 2.9: 3.8: 1.8: 2.

- ubm areas :: 4.4: 7.9: 3.8: 6.2- rural arms 1.4: 1.5: 1.3: 1.7

* ta for Andir include Taroudant province as well.

Soure: Miziatry of Public Bealth, 1984, and hAt & Cambes Report, 1983.

-59 -Annex BTable B.2

#IIUAT:I DISRIBUS N ABGECOMIM AM PD ARN

: Project Area 2/

Age Gr 1/rocco: 4Agsi Settat

(Z) :&Taroudmnt: (Z) aZ)

<1 15.2 2.7 16.01-4 14.95-9 14.3 15.4 16.9

10-14 12.6 11.5 14.515-19 : 10.9 8.0 9.42D-24 9.8 6.5 6.525-29 7.6 : 6.4 5.630-34 5.6 5.8 5.535-39 : 4.1 5.1 5.04044 : 4.3 : 4.5 5.045-49 3.5 : 3.3 3.250-54 3.5 : 3.6 3.455-59 2.2 2.1 1.5

>60 6.4 3.1 2.5

Sowce: Ministry of Public Health

1/ Baset m 1982 cenmis.2/ Base on 1971 census.

- 60 -Annex BTable B. 3

EON

EMR VEOR PDJBar Ac 'ICETW PREWA1W IN )IM

M AM RJB AREA - 1983

I l!etbod :N: occo Agadir Settat

I ' :''P Pill 16.8 16.9 18.6 I

11W m2 C.t 0.4

ubal Ligation 1.7 0.6 0.4 1

ICmdan 0.7 1.8 21

I Traditionml ethods 4.3 4.3 4.3 I

luTL' 25.5 24.2 25.7 I

Sourre: Natiotl Survey m Cotraceptive Prevalexe,1983-84, Apdir and Settat

- 61- Annex BTable B,4

FAMMY PLAN= ACCPMS1977-1983

I : :: I :: AGADIR (1) :: SEI

I DI. OF NW ND. F II ::AR :: :i.0AOPR IlI: :: l

P Pills : D :: Pills : D I

1 1977 :: 3,024: 87:: 4,594: 21I~~~~~ I

1 1978 :: 4,260: 188:: 5,386: 1581I ~ :: : :: :I1 1979 :: 5,968: 197:: 8,597: 421

I ~ :: : :::I1 1980 :: 7,370: 319:: 8,153: 831

I 1981 :: 10,363: 276:: 9,096: 411* :: : :: :I1 1982 :: 15,484: 404:: 11,215: 1511I :: : :: : I1 1983 :: 12,980: 456:: 10,192: 3481l :: : :: :I

(1) Includes Taroudant province

Source: Statistiques Snitaires, MER

- 62 -Annex BTable B.5

BMAUR DEVmEPIffl WFJC

mmIN MM :Fr ZONE

(1981)

I D. I . II I EsxMz I %P~A I Z t'I&A I

I I Si 1r I w SiR I S I

I~~~ ~ AI I I E I

~~~~I I AGI R I SErI * I I *IsI

URBA 17,8851 3,121 50 128 58 1581

X ~ ~~I I I I I I I* RUAL 146,751 129,8681 10 I 61 23 1181

I I 1 1 I I I IT OAL 54,636 132,9891 16 17.7 .28 1221

* Includes Tarodmunt province

Source: hmt amd Ca bes Rqport, 1983

- 63 Annex B

Table B.6

IN TZ (XM11 AND PODJEC ARA

Certified AuziliaryDoctors Nires Nurses Other Total

MODBOCO : 1,101 6,013 16,OZ 5,993 29,131

- Ambulatory 591 2,268 7,981 1,248 12,088- Hospital 510 3,745 8,046 4,745 17,046

AGADIR 44 197 463 411 1,115X= = -

-Ambulatory 11 70 223 42 346-Hospital 33 127 240 369 769

SETTAT :: 27 98 388 262 775

- Amulatory :: 8 11 166 32 217- Hospital 19 87 222 230 558

TABotOANr : : 13 32 174 122 341::= _-

- Abulatory :: 7 16 117 57 197- HoVpital 6 16 57 65 144

PYT= ARE A 84 327 1,025 795 2,231:: -___

- mbulatory 26 97 506 131 760- ospital 58 230 519 664 1,471

Source: Ninistry of Public Health, 1984.

- 64 -Annex BTable B. 7

MCMUEALUH EUNM PDWT

AIDILNA P3SOIU UE DJ FOR 7HE P1WBCT

: Certified Nurse: Axliay Nurses:Doctors: : Total

: Total % Fale: Total 2 Femle:

AGADIR

- Additiaml persomel :: 6: 35 77 50 42 : 91

- Increase* :: 14: 18 - : 11 - 8

- Additiml permel :: 3: 22 82 : 32 9 : 57-Z lncrm * :: 11: 22 - : 0.2 7

- ditiol persomel :: 2: 8 0 : 37 49 47- ncrese* :: 15: 25 - 21 - : 14

PF:: :A: :

- ditiml perooml :: 11: 65 69: 119 35 195- Z Icree* :: 13: 20 -: 12 - : 9

* Additil perscxmel generated by the project as percentage oftotal perscmel in the praoince.

Somme: Miistry of Pulic Hlth, 1964

- 65 -

Annex CPage 1 of 6

MOROCCO'EALTH PROJECT

CONTENT OF PROPOSED PRIMARY CAUE

PRIMARY HEALTH CARE CORE PROGRAMS

The uodel of Ambulatory Care to be implemented in Agadir andSettat will consist of six core programs in priority areas:

1. Immunizations (PEV)2. Family Planning3. Maternal and Child Care (PSME)4. Nutrition5. Front-line Curative Care6. Basic Sanitation

For each program, the major operational or technical changes are summarizedbelov.

I. UUZMIN

The iumunization program (PEV) presently reaches 45Z of nationalcoverage in 1982. Urban areas are covered at 631 vhile rural coveragestalls at 26Z. The project will support the nationwide immunizationstrategy by shifting from vaccination through periodic campaigns bymobile units to continuing vaccination by fixed posts - Health Centersand Dispensaries -- supplemented by mobile units in rural areas. Thesmaller rural dispensaries (DRB) vill not be included as imunizationoutlets, for reasons of cost-effectiveness of vaccine utilization andtechnical control. Detailed programming of vaccination against sixdiseases -- Diphtheria, Tetanus, Whooping Cough, Measles, Poliomyelitis,and Tuberculosis - under the nev approach will increase the immunizationcoverage in Agadir and Settat from the present 361 to 601 in 1987 and801 in 1990. In addition, the strategy will allow for the coordinationof immunization activities with prenatal clinics and clinics for childrenunder five years of age, sore convenient for consumers and providers.The shift in strstegy requires: a) expansion of the cold chain to 47nev facilities, b) provision of equipment, c) retraining of personnel,d) improved IEC support, e) vertical monitoring of operations at provinciallevel, and f) operational and evaluative research. The cold chain,logistics and equipment specific to imsunization will be provided byUNICEF while general equipment, training, I8C, monitoring and researchvill be provided by the project.

- 66 -

Annex CPage 2 of 6

II. FAKIIT PLANIUIh

In the three project provinces, the family planning programmill mobilize the following combination of resources:

(a) All 48 smaller Basic Rural Dispensaries vill deliver familyplanning advice, and contraceptives. All 65 larger RuralDispensaries, which will be staffed vith a female nurse asas vell as all 43 Health Centers, vill carry daily familyplanning clinics with capacity for IUD insertions.

(b) At the peripheral level, family planning clinics held indispensaries and health centers vill be complemented by theoutreach activities as described in para. 1.09. In the caseof concentrated populations or populations located within10 kas of a facility, the outreach vill proceed through bomevisits. In the case of distant populations family planningprograms vill be delivered through biweekly clinics at meetingpoints, mobile teams or, in the uost remote areas, by comunityworkers and traditional birth attendants.

(c) All Health Centers and Hospitals out-patient services villserve as back-up level and will operate FP and gynecologyclinics manned by specialized female nurses and physicians.

Cd) The specialized fa._ily planning centers in Agadir, Settatand Taroudant provincial hompitals will provide tubal ligationsand specialized back-up to family planning.

(e) IEC services will provide support to all family planning servicesand promotion activities in the comunity.

The objectives of the program are:

(i) to provide information on family planning and contraceptivesto jL women in reproductive age. To improve knowledge ofmodern contraceptive methods including IUD and tubal ligation,from present 63Z to 90% of women in reproductive age in 1989;

(ii) to increase total contraceptive prevalence in the projectarea from the present 24.7 to 33 in 1989. Contraceptiveprevalence targets by province will be as follows:

1983 1987 1989

Agadir 24.2 30 36.3Settat 25.7 31.8 38.5Taroudant 15.2 18.8 23

- 67 -

Amnex CPage 3 of 6

Increase of total contraceptive prevalence will be obtainedthrough an improved follow-up of recent acceptors (drop-outrates are high in all three provinces) and tbrough widerutilization of IUD - presently les. than 21 of KWRA -- to62 by 1989, and tubal ligations - presently 1.7Z of HURL- to 41 in 1989.

(iii) to avoid teenage pregnancies, lengthen birth interval anddrastically reduce high parity pregnancies as well as pregnanciesin the 35-44 age group.

(iv) to increase and improve IEC support for family planning, byaudiovisual methods and mass media channels in urban areas,and by IEC mobile units in the distant rural areas.

(v) to carry out operational research on acceptability of ZUDand implants, continuity rates by methods and impact of IEC.

III r NIERAL AMB CZ=LD CARE

Expansion and improvement of NCR -- particularly maternalcare and family planning - depend to a large extent on the staffingof peripheral facilities vith a female nurse in charge. Maternal andchild care will be delivered in close coordination with im-unizations,family planning and nutrition through two activities:

(a) Prenatal and Obstetrical Care. The activities will bereoriented according to three operational objectives:

(i) to expand the coverage of prenatal clinics to 35Z ofall pregnancies - as compared to the present 5.4Z -

focusing on high-risk pregnancies;

(ii) to improve the conditions of deliveries in health facilities;

(iii) to improve the conditions of home deliveries throughhealth education and supervision of traditional birthattendants by the health services;

(iv) to secure hospitalization for high-risk deliveries.

The project will implement standardized clinical and laboratoryprocedures for prenatal aid obstetrical care, based on riskassessment; retrain and re-assign 60 female nurses alreadyin service, to carry out prenatal and FP activities in ambulatoryfacilities; train and supervise traditional birtb attendants;upgrade existing maternity beds in rural health centers andprovide for two additional rural maternities.

- 68 -

Annex CPage 4 of 6

(b) Postnatal and Clinics for Children Under-Five Yeagr of Ate.Periodic clinics for postnatal -- including PP care - andgrowth monitoring of cbildren under five will be expandedto 77 facilities in the project area. Present coverage ofmother and infant under one year of age will increase fromcurrent 202 to 30S in 1987 and 551 in 1990. Special attentionwill be given to imunizations (I above) and control of diarrhealdiseases, for wbich detailed procedures have been prepared.Control of acute respiratory infections will be introducedin 1987 under WH0' LachaiC&l a8SicStancC.

IV. *NDITICE

In coordination with other government agencies and assistancefrom UNICEF, USAID, World Food Program and UNFPA, NOPE has initiatedinterventions at the national level such as: reactivation of the productionand marketing of Actamine; research of alternative supplementation formulas(such as ANDY), introduction if nutrition activities in the programof the Mobile Family Health bnits (UMSF), and reactivation of theInterministerial Commission on Food and Nutrition (CIAN).

Under the project, a limited number of well-defined interventions,integrated in the PSME program, will be implemented in Agadir, Settatand Taroudant:

(a) The major operational innovation will be the detection andreferral of malnourished children and pregnant women byitinerant nurses or uobile teams, either by home visits(Strategies 1, 2 and 3), or at Contact Points (Strategies 4and 5). Similarly, villages, hamlets and pockets of povertyat high riak of malnutrition will be identified and screened(active detection). This approach will permit the detectionof malnourished ehildren below 5 years of age whose wast'igor stunting seldom motivates consultation.

(b) Introduction of PSME units, staffed with female nurses, in theperipheral facilities, particularly the Rural Dispensaries,will facilitate th.e fclol-up of referred cases and the long-termrehabilitation of malnourished children and pregnant vomen.In addition, pwsetnatal clinics will contribute to the detectiouof malnourished infants and toddlers of 0 to 2 years of ageby systematic growtb monitoring (passive detection).

(G) Generalization of nutritional rehabilitation by the mother athome - rather than at the hospital, by improving the fauily'sdiet and cooking methods instead of providing supplementsespecially intended for the patient which are expensive andseldom reach the child. This approach reduces hospitalization

- 69 -

Annex Cpage 5 of 6

costs but requires increased supervision by itinerant nursesor mobile units according to the different outreacb strategies.It also requires a dependable supply of supplementation nutrients.The intervention has undeniable educational value but needsto be precisely targeted if it is to remain within the presentlimited budget.

T. yaU LIM cURTvE CAN

MOPH acknowledges the necessity to improve access to the healtbservices. During project preparation, consultations with representativesof the coumunity have underlined the need for effective basic curativecare as a prerequisite for any further intervention in preventive care.Objectives were set in three areas:

(a) Hospitality: Improved reception and orientation of patients,improved orgenization of clinics and changes in working hoursfor consumers' convenience, decrease of waiting tine, easieraccess to nurse or physician, facilitation of referral andtransportation.

(b) Ouslity of Core: More efficient response to the felt needs,improved laboratory and X-ray services, assistance in trans-portation of emergencies, facilitation of admissions to hospitals,continuity of care and medical records, standardization of

5 treatments, provision of basic emergency dental care.

(c) DisnensinE of Basic Druns: Improved supply of appropriatedrugs, correct prescription, efficient dispensing.

Civil authorities, traditional and religious leaders havemade clear that continued participation of the cou.m.ity in health mattersis likely to be conditional to progress made in those three areas.To assess present and potential deuatd for care, a study of consultationwas carried out in Agadir and Settat during project preparation. Causesof consultation were surveyed and the effectiveness of the medical andsocial answers provided by the health services was analyzed. NOPR nowhas a precise profile of current demand and a good insight of majorflaws; a timetable for improvement has been set according to each oneof the six proposed strategies. In view of the importance of qualitativeimprovements. progress will be closely mouitored and several protocolesfor operational research were designed for the verification o' effec-tiveness and assessment of costs.

VI. "SIC IATIO

NOP's approach to sanitation is realistic and interventionsare well-designed. Priority is given to drinking water for wbich thereis a felt need, and collective interventions are well-accepted and

- 70 -

Annex CPage 6 of 6

financially feasible. Some of the densely populated areas require,however, inutallation of latrines which, conversely, are not traditionallyaccepted, derive from individual initiatives and are relatively expensive.

Caution has boen exercised against introducing in rural orperiurban areas costly uodern solutions wbich may be culturally andecologically unadapted. Priority has beeD givan to support andimprovement of local initiatives.

The following objectives, allowing for variations accordingto the terrain and settlement, are set for Agadir, Settat, Taroudant:

(a) In urban areas served by house convections or public standpipesand sewage systems, bacteriological control and chlorinationwill be improved.

(b) In rural areas, wells, cisterns anI other groundwater pointsalready surveyed in 1983 will be placed under bacteriologicalsurveillance by health personnel according to Strategies 1to 5. Wells and cisterns, within 5 koe of a bealth facility,will be limed periodically or treated by continuous cblorinationwith locally made chlore diffusers. Cases of typhoid willbe systematically followed up in the coemunity. In specificareas, particularly in Settat, ground waters will be testedfor fluor, nitrates and ferrous sulphate.

(c) Improvement of 200 wells, cisterns and greundwater pointswill be made cs demonstration projects, in collaboration withthe Ministry of Agriculture, in scbools, mosques, souks orvillages. Financial participation of the comunity will besought for the civil works in exchange for information, trainingfor local workers and technical advice by NOPE.

(d) Demonstration activities will also be carried out for householdwater conservation -- local construction of filters, utilizationof storage tanks, and improved bandling of water. Kxperizentalconstruction of latrines will be carried out in selected villagesand periurban low-income settlements.

(e) Coordination will be established between several water supplyinterventions - handpumps and plastic water tanks installedwitb UNICEF assistance, emergency relief by public water trucksand Bank-financed water supply developments in liougra, Taroudantand Ouled Teima in Agadir province and El Gara in Settat.Responsibilities of the Health Services will be coordinatedwith those of ONMP and the Ministry of Agriculture.

Iuplentatian of this progrin will require upgrading of publichealth laboratory facilities, laboratory fixed and portable equipmentand umterials as well as a dependable supply of chlorine and line.

- 71 -

Annex DPage I of 3

MOROCCO

HEALTH PROJECT

Proposed Strategies for the Deliveryof Primarl Care

Based on precise mapping of population settlements and fieldstudies carried out for project preparation, MOPE identified differentcombinations of resources for delivering primary care in a cost-effectivemanner. Several combinations of resources - known as "strategies"- use fixed facilities and outreach in different ways according topopulation density and dispersal, terrain and socio-economic organization.In rural areas of Agadir, Settat and Taroudant, the strategy to be utilizedfor each settlement, village or commune was discussed with health staff,civil administrators, religious and community leaders. In most cases,a formal agreement was reacbed between MOPH, civil authorities and thecomunity leaders on the contribution expected from each party. Sixstrategies will be implemented:

SIDATEY I1

Concentrated Ponulation (small towns, periurban developments,villages). A fixed facility - urban or rural health center, urbanor rural dispensary, according to the population - will deliver thesix core programs through general clinics, open to all patients, andspecialized clinics - prenatal, family planning, tuberculosis, NCR,pediatrics -- held on specific days each week. Emergency care willbe available at all times by staff on call. Health centers will bestaffed with physicians, dispensaries will be staffed by nurses, withat least one female nurse. Residents live within walking distance andwill be expected to aeek preventive as well as curative care at thefacility. Rome visits will be limited to the VDMS and special purposessuch as epidemiological inquiries and control of bedridden invalids.

3SRAPF 2

Populations located between 1 and 5 kms of a health facilitywill still be expected to seek curative care and follow preventive clinicsat the facility. Preventive care vill be complemented by home vi8s.tsby an itinerant nurse equipped with a bicycle or moped - five visitsper year for the VDMS, special visits as in Strategy 1, and visits forthe control of wells and basic sanitation. An interplay will developbetween the facility and the outreach a'tivities.

- 72 -

Annex DPage 2 of 3

STEATKG! 3

Population located between 5 and 10 kUs vill be expected toseek emergency and curative care at the facility. It is however unlikelythat the population will follov preventive clinics. Outreach activitiesbecome the main element of the system. Itinerant nurses equipped withmopeds or motorcycles vill make home visits and vill be trained to provideboth curative and preventive care.

SAQI 4

Dispersed populations located beyond 10 km8 of a facilityare unlikely to seek curative or preventive care on a continuing basisbut only emergency care. Multipurpose clinics for curative and preventivecare vill be held once or twice a week at conveniently located MeetintPoints. These clinics vill require a paramedical staff of two to threepersons with a light vehicle and portable equipment.

5

Dispersed, distant, nomadic populations, or settlements thatare isolated during part of the year by rainfalls or snow, vill be servedby mobile teams. on a periodic basic - five times a year. At eachvisit, curative and preventive care should be delivered as a one-timeoperation. This modality will require a staff of three to four, largervehicles and heavier medical and dental portable equipment.

SlU*FGr 6

In the case of isolated clusters of population, where socialorganization of the community is propitious, utilization of co unitvhealth vorkers may lend better results at a lover cost than the mobileteams. Voluntary health vorkers and traditional birth attendants, underthe control of the community leaders and periodic supervision by nursesupervisors vill serve as outposts of the health services. This approachvill require well-trained supervisors and vehicles adapted to the terrain.

By constructing additional facilities in the rural areas -

48 basic rural dispensaries and 37 rural dispensaries - the projectwill improve the percent distribution of rural population by distanceto the nearest facility:

- 73 -

Annex DPage 3 of 3

Current Proposed

-3kus 3-5kus 6-9kus +l0kms -3kms 3-5k=s 6-9kms +l0kus

Agadir 23 14 24 39 40 20 19 22Settat 24 12 41 23 42 19 33 6Taroudant 14 10 18 59 27 19 28 26

Besides distance, a variety of criteria was utilized todecide on the strategy to be used for each settlement. Strategies aretherefore distributed to fit local needs realistically. The distributionof population by strategy vill be as follows:

WDEA3E aF RLNAL POPATMU(By Projert Stmteies)

I I A'ADJR A SE=IAT TAmN

I S _ _ _ _ _ - -_ _ ___ _ _ _ _ __ I

I I PIATIIUE % I Lou AItaMA X IP OFUIAL N % I

I I aaI EDI aaI

I1 and 2 (fixed pos) 2 2D3,072 57 1 357,820 58 1 227,799 43 113 ad 4 (itinurnt) 1 95,152 27 1 125,192 20 I 2D9,185 40 115 and 6 (bile tenm or 1 58,955 16 1 136,468 22 1 87,457 17 1

cuzmmity agent) IIIII I 1 1 1

¶TOML I 357,179 100 1 619,480 100 1 524,441 100 1

SOURE: Mini"ty of Public Hbalth, 1984.

- 74 -

M Annex EWLTH rEHM PR=

oWIZATIN OF TIE WAm CAKE IFLIERY SYSTEM

LEYL ETDiL TEOR FIXED AW & IOP. 1311(M IN SERVICS

LOATION FWILITT mmEVE STRAMT CwE WFEED

Pclatim inaccessible - - S6 - ommity Local Villager kith First aidpart of the yer Driers MUler ad Traditiuaal Distributio of Basic

Birth AtteSt Mum ad tntracetivesLiaiseuth ilth Services

Distat ard dsesed - - $ lmile I fl.D., 3 paeicals Owewnmive or clinics,or nomadic pepilatim Clinics in Nfbile Clinics ere vwgas

Orative careIStal care

Disersed pwulation - - St - Weting 2 pardcals in 1eky half-way clinics fork mO Ib of a PoinW ligt vehicle 6 core proWfixed faility

fil Villages Basic Rural 5,00D S2 & $ - Hme 2 ale paruedicals 5 core powas, plus VMUDisea Visits VIE) alte ting after ard imizatiors

Large villas or Dispensary 15,000 S2 & S - H1 2 ale paredicals, 6 care pro f IURsSubrb areas Visits (WI) I feule nwse ad iniLatirns

f nrme

mieftm of klth 45,00 S1, S21 3- l or 2 lI.D.s, 6 to 12 6 core pr,Districts Center HOnW Visits paraudicals specialized clinics, bck-w

(VI) tlaboratury ad x-ra. Sad mweratim for S4, 53 adaprvisiun of S6

Kajar TIS ral 200,00D - 6 to 10 L.D.s, 24 to Dnter ald nilHospital 40 pnedicals srgery, Pediatrics, oU-GNf0l0beds

CIpital of Prince Ptrdncial 60,OOD - 25 to N.D.s, 10 to AllU ior clinical adospital 20 peruedicals sagical specialties.*-300 beds

catlm a t 2 thiversity 21,00,00 - All s-p aitieshopitablsTotal 1100 bd

- 75 -

Annes FPage 1 of 4

MOROCCOHEALTH DEVELOPMENT PROJECT

Structure and Resuonuibilities of theDivision de l'Infrastructure Chargfe de la Planification (DICP)

A. PLANNING

The planning section of the DICP has developed through projectpreparation and is presently staffed by three physicians, an economist,four instructors in nursing (cadristes), one administrator, statisticians,computer programuers and support staff. Part of this staff - one physician,one cadriste and one administrator -- will be assigned to the ProjectImplementation Unit (PIU), and will only be available to the DICP part-time.Before negotiations begin, two economists and a social scientist willhave been recruited. The DICP has successfully made good use of foreigntechnical assistance and at present employs three full-time advisersfinanced by USAID and two full-time WHO advisers.

To meet its responsibilities in the preparation, advocacyand isplementation of the 1986-88 three-year plan, the DICP will developseven functiunal units or task groups, some of them permanent, otherstemporary. Task groups will also utilize professionals from otber MOPEdepartments to help on particular problems. The units will be as follows:

1. Lont-ters Planning vill examine the long-term options forthe sector, thus providing a framework for short-term planningand research.

2. Short-term Plannin& will prepare the three-year Plan and coordinatethe consultative process within and outside MOPE.

!. Manpower Planning will reviev the performance and costs ofthe main categories of personnel in collaboration with theTraining Division and the Division of Personnel, as a basisfor estimating future requirements and needs for training.

4. Health Programs vill set standards and annual targets forthe health services, and monitor tae implementation of healthprograms in the provinces, in particular in the three projectprovinces, in collaboration with the PIU.

- 76 -

Annex FPage 2 of 4

5. Physical Planning presently regulates the creation of newoutpatient facilities. The scope of the unit will be extendedto include hospitals, and the unit will work in cooperationwith the construction unit of the DAA.

6. Biomedical and Hospital Technology. This unit will controlthe acquisition and utilization of biomedical technology -laboratory, radiology and radiotherapy, electro-medical diagnosis,-- where major investment and recurrent expenditures are entailed.

7. Research and Evaluation vill coordinate the research and evaluationprogram described in B below.

B. STUDIES

The Health Development Plan for 1981-85 sets the followingresearcn objectives for possible Bank financing: a) to carry a detailedanalysis of the health problems and problems posed by health care delivery;and on that basis, b) to establish and implement appropriate programsin the Basic Health Services (Agadir, Settat and Taroudant); c) to assessthe costs and benefits of programs; and d) to prepare their extensionto the rest of the country. Emphasis was placed on establishing a permanentresearch capacity in MOPE for management and planning purposes.

three main research areas are proposed: a) health servicesmonitoring; b) financing of the health sector; c) hospital managementand performance.

Health Services Monitoring

Health services monitoring will cover three main areas:

(i) Evaluative research on performance will be based on standardinformation collected monthly or weekly by all health facilitiesin the three provinces, and focusing particularly on:

* Accessibility and effectiveness of family planning programs,number of acceptors and contraceptive prevalence.

* Accessibility and performance of MCB programs. Catchmentareas and gradients of care.

* Outreacb activities. Performanve dnd output of itinerantnurses and mobile teams.

. Referrals.* Sanitation/Drinking vater. Number and type of activities

performed.

- 77 -

Annex FPage 3 of 4

(ii) Operational research on alternative method of delivering carevill be based on information collected by selected healthfacilities. This research vill call for experimentation ontechniques and/or organization and management, carried outin rural areas of the provinces of Agadir, Settat and Taroudant,plus six other provinces. Priority areas vill be:

H Methods of contraception.* Utilization of IEC materials.* Techniques for monitoring pregnancy, growth and nutrition

rehabilitation.* Distribution of health teams.* Quality of reception and orientation of patients.* Domestic use of vater.

(iii) Monitoring of bealth indicators - a statutory joint reponsibilityof the DICP and the Division of Epidemiology. Three priorityareas have been identified:

* Follow-up on the study of contraceptive prevalence.* Follow-up on the study of infant mortality.

Application of the findings of the National HouseholdSurvey of Expenditures on Nutrition for nutrition program.

Most of the evaluative research will be carried out directlyby the staff of the DICP with the participation of other Divisionsof MOPH assisted by Moroccan or foreign consultants, MHO andUSAID advisers as necessary.

Most of the field research vill be carried out by provincialstaff under the supervision and technical guidance of theDICP, with the assistance of consultants as necessary. Researchthat requires specialized capacity vill be carried out undercontracts for the DICP by faculty and graduate students ofthe Departments of Social and Preventive Medecine of Rabatand Casablanca Universities.

Study on the Financin2 of the Health Sector

The GOM gives high priority to a comprehensive study on thefinancing of the sector as a follov-up to the 8ealth Sector FinancialAnalysis prepared by the Bank in 1983. The study will cover the public,parastatal and private subsectors. The first phase of the study villanalyze the financial flows in the sector. It vill reviev the sources,channelling and allocation of resources for health activities - includingthe Rabat and Casablanca University E,spitals but excluding social welfare- and will assess the equity and efficiency of the system. The secondphase of the study vill explore alternative methods of financing:modalities of cost-recovery, the expansion of social security or insurance

- 78 -

Annex FPage 4 of 4

schemes, and indirect revenues. The Bank vill have an opportuniL7 toexpress its views before any policy based on the study vas put intoeffect. The results of the first phase are expected by mid-1986.

The study vill be directed by a Steering Comittee vith theparticipation of the Ministries of Health, Finance, Planning and EconomicAffairs, and carried out by a Task Force under the direction of theSecretary General of NOPR. Technical coordination will be providedby the DICP with technical assistance from local and foreign consultantsor uultilateral agencies.

The project will finance contracts for services and technicalassistance for the preparation, discussion and publication of the study.

Study on Hospital Performauce and Management

Increasing demands for hospital care lead to delays in theadmission of patieuts referred by the outpatient services. In addition,the escalating enats of hospitals threaten the financing of outpatientservices. Rerearch on hospital performance and management is urgentlyneeded to increase prodactivity and reduce costs. The study will covera sample of selected hospitals inside and outside the Project Area:six provincial hospitals (Agadir, Settat, Narrakech, Fez, Neknes andKenitra) and four district hospitals to be selected.

Basic data on costs of provincial and district hospitals werecollected in 1983 and 1984, so that the study will focus on organization(clinical and support services), performance (quantity and quality),and management issues in 1985 and 1986.

The study will be carried out by a consulting firm assistedby MOPE vith the technical assistance of local and foreign consultants.

The project will finance materials and local expendituresrelated to the study, data processing, contracts for services and technicalassistance, seminars to discuss the findings and their application andpublLcation of the results.

- 79 -

Annex CPage 1 of 3

MOROCCO

HEALTH DEVELOPMENT PROJECT

SuDDly of Basic Druis

Since 1979 MOPE has been concerned with the progressive shortageof basic drugs and the Central Tharmacy's aging facilities, and hasexplored alternative supply systess. In search for solutions, theDirection des Affaires Techniques has coordinated the work of WHO andUNICEF consultants and technicctl assistance by Management Sciences forHealth (MSH) financed by USAID, as well as assistance offered as courtesyof the local pharmaceutical industry. MOPE and/or consultants preparedeight technical reports on public health, pharmacological, engineering,architectural and economic aspects of the drug supply system vhich areavailable in project files.

On the basis of these technical reports, discussions withBOPH officials and representatives of the pharmaceutical industry, theAppraisal Mission agreed that the reorganization of the drug supplysystem is an urgent necessity. For NOPE's operations, efficiency requiresthat the several managerial, administrative and technical functions- selection of drugs, standardization, budgeting, ordering, procurement,reception payments, storage, packaging, distribution and supervisionof utilization -- be regrouped under a single agency. This opinionis strongly supported by the health services, wholesalers and manufacturerswho will then deal with one agency rather than several administrativeunits in different departments of MOP8 and Ministry of Finance. Thereal issue under discussion has been the opportunity for MOPE to buybasic drugs, either locally or abroad, or to formulate its own basicdrugs. The Appraisal Mission revieved with MOPE officials, WHO, UNICEFand USAID consultants, three major alternatives.

1. Formulation I by NOPH

NOPH's Central Pharmacy will continue to formulate some 46basic drugs for primary care, and will improve and increase its outputto make up for the present shortage and meet future needs. This alternative,originally proposed by MOPE, was included in the 1981-85 Health Divelopment

lote: "Formulation" is the final stage of drug production, from inter-mediate ingredients to final or finished form. It consists of simplemechanical operations such as mixing, solving or dispersing, and fragmen-tation into dosage forms (tablets, capsules, tubes, etc.). By comparison,"productione covers the entire transformation process from raw materialsor basic chemicals to intermediate ingredients and final formulation- it consists of complex physical/ehemical operations such as extraction,fermentation and synthesis.

- 80 -

Annex CPage 2 of 3

Plan. It vill require, however, a US$10 million investment to constructand equip a nev plant according to regulations and prevailing standards;acquisition of advanced technology (i.e. in the formulation of antibioticsand toxics), and a substantial increase of staff -- from the present32 to 115 workers. According to MOPH's atudies, expected savings, ascompared to procurement, could offset the amortization of investmentsand the additional operating costs, although significant risks - technicalas well as financial -- will be involved.

2. Procurement of Finished Basic Drugs in Bulk

HOPH will procure all the 46 basic drugs needed for basichealth care, either in the local market or in the international market.This alternative will spare NOPE a major investment and greatly simplifyits operations. Only a small formulation laboratory, such as all majorhospitals have, vill suffice to prepare about ten basic solutions andointments. A packaging unit will still be required to convert the drugsin bulk into single-dosage packages. The local pharmaceutical industry,however, has consistently shown little interest in tendering for theformulation of low-cost generic drugs, which will require immobilizationof capital and production capacity, for minimal benefits. KOPH's basicdrugs will only represent 2Z of total drug expenditures in the country.For similar reasons, joint ventures have not been attractive for theindustry. Procurement of basic drugs under finished forms in theinternational market proved expensive in foreign currency, and thefinished forms did not always fit the needs of primary care. MOPE hasevidence of many failures with procurement of finished drugs over thelast years in spite of the declared good will of the industry.

3. Toll Formulation

This alternative has developed recently in many middle-incomecountr es. Documented experience existc for India, Tunisia, Braziland Cost* Rica among others. Toll formulation consists of Governmentprocuring intermediate ingredients on the international open marketand contracting vith local industry for the formulation, on the basisof costs plus an agreed-upon benefit. The finished product is deliver-din bulk under the Government's label. Toll formulation allows forconsiderable savings by purchasing ingredients in the open market andwill spare NOPE major inveatments. It is attractive to the local industrywhich will use its idle capacity witbout imobilizing capital. Theindustry will be ready to toll-formulate the more sophisticated drugs,such as antibiotics, for vhich idle technology and installations cannotbe utilized for other purposes. Eowever, for the simplest drugs whichrequire virtua!.ly no technology and only standard equipment, the industry'sidle capacity can be utilized for otber products, such as cosmetics,for much larger profits. This alternative still requires from the CentralPharmacy an accurate planning, an excellent procurement capacity based

- 81 -

Annex GPage 3 of 3

on up-to-date information on international market prices, and flexibleand rcpid procedures for contracting and payment.

Having reviewed these alternatives with the assistance oftwo consultants from the pharmaceutical industry, the AppraisalMission agreed to the final MOPE proposal, vhicb, in turn, meets thelocal industry's approval:

MOPH will procure ingredients in the open international marketand vill:

(a) Contract with local industry for the toll formulation of anti-biotics and some six products requiring sophisticated technology.The industry will utilize its available capacity of non-versatileequipment and deal witb the most expensive and therefore profitabledrugs. HOPH will be spared an investmeat of about US$8 millionin sophisticated and rapidly changing technology and equipment.

(b) Formulate in its own facilities the simplest high-volume,low-cost, minimal technology products wbich yet representthe most comon drugs in every day use in the health services- pills, powders, ointments, solutions, syrups andsuppositories. The industry will rather avoid these cumber-some operations. For the formulation of this group of drugs,NOPS will only need an additional investment of US$1.3 million(as some of the present equipment could be utilized), andminimum additional staff and acquisition of simple technology.

The proposed project reflects these conclusions.

- -- -- -- -- -- -- -- -- -- -- - - ---

'4 r

|-~~~~~~~ I U B f j |.

il;Sii ii $ Iji

u 0 I k J J z j t~~~

0 5

-~~~~~~~~~~~~~~~~~~~~-

i a! V3 %§ git E3" 3i g i' j. . . . . . . . ___

____ __"_e____-_@_h___^S

- 83 Annex CTable C. 2

MOROCCOHEALTH DEVELOPMENT PROJECT

The Dmg Supply System - Sequence of OperalbnsControl and Feedback Mechanisms

jSt ofau(VIW~ 1 1

-- ^6I I Du Cltrv--

N _ ~~~ono *

I, I< Fnno D cm mt

Accamntmg J Itocuman

ACcoucb I

l_tw_wd_t_ Sk-ooI

J, -- % -1 Qvoft Cc- I* Conbo t owt |

.+~~~~~Cn~o~ IC CP I vn 'w rus I

D~._ t'.__._o

-~~~~~ ._._._._.i- I

S"wvoCx w0

r---- Pib5OtO_w I---

- C-smaft'wocv OW'S Mrt4 5 SWOS .'

- 84 - TAbl e .1

MOROCCOHEALTH DEVELOPMENT PROJECT

Otgonizotton Chart of the MinWtiy of Pubikc HoIm

F LWJ Mrms,w Of

L~~~~~~~2J7~~~~~~~~

SWCfW ArArefttVM~

Gltnuw & cwtkGn-Dr A Conft Do ho of D d

-k TWnAM _o Ad"WlffhwwAf

So~~~ ~iOffy Of .n iift* HeOfi Gng%

t0 OsurOfed_ - i I Ihs P'o

l ~ ~ ~ mrn Eckicoc C at - Acuig"3tIPOW _ON c._C - &ai PSC nr, _FW% Dwg -- aeSum4 - llua@t4o Ltwaclh

Vvta L hlllollion

SW"r wm of Raft ,

-85- Annex HTable H.2

MOROCCOHEALTH DEVELOPMENT PROJECT

Project Implementation

Public Hech

| I lleD eot | e oTednlical Affirs Directate of

| - ~~~~~~~~~~~~~~~~~~~Admin. Alicrs

,Dug SuPPUnit

Division de n College of Division of Irln0rostructurieDisonOBug&

Publc Heatth Population chorgee de la EqIpnaontPicanilication proe

- - ~~~~~~~~~~~~~~~~~.

Ftincenof I Pronce of i| Sett ll Agodir T[ oucnt |

Legend:

Pmject Implementation Auijht Line

- MOPlsGenewo Authoity Line

World Baor-26967

- 86 -

MOROCCOHEALTH DEVELOPMENT PROJECT Annex H

Implmentatlon Schedu Table B. 3

19 1905 1510 19l7 *O 1909 1990

,l2 13 14 ., 2. 3 a2J 1 I2 3 4 1 2 3 . 1 l2 3 4 .11 2 3 I4_ _ _ _ _ _ _ _ _ _~~~~~~~~~~~~d~ I If ICOMPREIOJ/ACIIVUECI 3AR I WAR 2 W| R 3 T R4 VEAR 5

-w u

hpu.m -. i KU staf

of~ P13 staff

s. - w= azci1 -1 .I Li

L - - b-iU .=NOW

am~i ci haicth .rL

P. uwf .It]T

?lig U1siuS i t ffad

at-f !. a p 13. sts

UP - he .of amU4 bad& hPi

TWu-im Cm- £tsimcitiimpi

W~~~mi of muff_ ||W| f <7 _ft actlir Mona FM=' Is

- lpaii of p sct pin- qumylcin o W-m P

-Finift of do smctw lot jift-- r

- i~~~Iinpwtatim

Mx. 7aMB 6 DC 00nmCaUDs c of' pm t co apdpJ veichss

I: Pho. of prfint* & h-V spip.fg p. ofdml pvqPzoi. a iqmtiinm Of yvcsmDimm&tim in 3 projwet psasmm

W inrt ofcomny

Hamiat ci IEp.

ftW. of ima sUs & bidiixin

Pip.mn of onI comm &*ts

P wsti. ci "*mmin P-

1nmft ce ni tUumti

activity Vj ak2%

* plAnned output

I-T ------------------------------------------------------------------T -l----I

I P

Phh$~~~~~~~~~~11 '* i* 1 q Jill S>

.A CP; V tA e U Nh, 0

"~~~~~~~~' ,,,, , U. SS''SS i ,t

8 ~ ~~~~~ I, I, I" I W I40 " 4.W. " cs . " n19 I I I I I -1 I 1^N 1 17 -""~~~~~- as 1-- ta t, 8 I M- 1 W " , ,, " , ,W.I 1 "F WtoR

g~~~~~~6 I I I"" I t: I I 0- I I I _" I I I b_U I. I I I I I I I I I I" | - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -t

5.~, 1¢ 1. I *1. ,_,1.P .,l@1if 111111 I ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ *I~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~~_ ___ ___________ __________

-88- Annex I

Table I.1

m - wp4trr8 SCMElM clEr Te

ohin-im US$)

I :: : k : teU hli ndI Fiscal Year/ :: Dislxlts : Isbswsuiet : blanceI Sester : II ::4!Dalts: Z :Mnmts: S :~IZt: I II .I

IFY16 1:8I :: : : : :IIDecember 31, 1985:: 0.3 : 1.0 : 0.3 : 1.0 : 28.1 : 99.01IJume 30, 1986 :: 1.0 : 4.0 : 1.3 : 5.0 : 27.1 : 95.0

1171987 ~:: : : : : : II ~~~~:: : : : : : I

Deember 31, 1986:: 1.4 : 5.0 : 2.7 : 10.0 : 25.7 : 90.0 1June 30 1987 :: 2.3 : 8.0 : 5.0 : 18.0 : 23.4 : 82.0

IFY 1988:: : : : : : II :: : : : : I

Deceiber 31 1987:: 2.6 : 9.0 : 7.6 : 27.0 : 2D.8 : 73.01June 30, 1988 :: 2.8 : 10.0 : 10.4 : 37.0 : 18.0 : 63.0 1

I ~~~~:: : : : :: II F1989 :: : : : : : II :: : : : :: lIDecember 31, 1988:: 2.6 : 9.0 : 13.0 : 46.0 : 15.4 : 54.0IJune 30, 1989 :: 3.4 : 12.0 : 16.4 : 58.0 : 12.0 : 42.01I :: : : : : :I F1990 :: : : :

I ~~~~:: : : : :: IDecember 31, 1989:: 2.6 : 9.0 : 19.0 : 67.0 : 9.4 : 33.01IJune 30, 1990 :: 3.4 : 12.0 : 22.4 : 79.0 : 6.0 : 21.0I :: : : : : :

IFT 1991 : I - :: : : : : 1

IDecember 31, 1990:: 2.8: 10.0 : 25.2 : 89.0 : 3.2 : 11.01IJune 30, 1991 :: 1.7 6.0 : 26.9 : 95.0 : 1.5 : 5.0

I ~~~~:: : : : ::FY 1992 :: : : : : :DecmbrI - , 9911- :: .: : : :Ieceier 31, 1991 :: 1.5 : 5.0 : 28.4 : 100.0 : 0.0 : 0.01

I ~~~~:: : : : : 1

-89 - Annex ITable I.2

MOROCCOHEALTh DEVELOPMfET PROJECTProJect Comanents by Year

(DIRHANI '000)

Base Costs Total

198511986 198611987 1917/1188 198811989 1989!1M DIPHAI CUSS 000)

A. DLPMENT OF BASIC HEALTH SERVICES 179079.6 4B,618.1 58,333.4 55,595.7 39,632.6 219i259.4 23,153.1B. STREN6TIEIN5 NOPH W6E 49547.4 39965.9 3%577.5 2,917.5 1,010.3 16,0o8.5 1,691.5C. STRENGTHEN1N6 TRAINING AND IEC CAPACITY 59309.0 5,211.9 1,948.5 1,187.5 1,029.4 14,686.3 1,550.8D. DEVELOPMENT OF DRU6 SUPPLY SYSTEM 5,269.7 15,586.9 29,411.4 14,560. - 64,829.0 6,845.7

Total BASELINE COSTS 32'205.8 73P382.7 939270.8 74,261.6 41,672.3 3147793.1 33P241.1Physical Contingencies 29581.0 6,358.0 8P111.9 6,250.7 3,084.6 26,3B6.3 2,786.3Price Contingencies 24817.1 139582.8 250735.0 27,844.8 199866.2 899846.1 9,487.4

Total PROJECT COSTS 37,604.0 93,323.6 127,117.7 108,357.1 64,623.1 431,025.5 45,514.8__== -- -- -- = -== == ===- ___ __=

Taxes 6r287.4 14905.2 20,789.7 14,836.4 109571.4 67,390.0 7v116.2Foreian Exchange 19,158.8 44t940.4 67y468.4 589771.2 29i654.4 219,993.2 23r230.5

Aipril 19, 1985 15:49

- 90 -Anue ITabl- 1.2(cmlt'd)

H6HLTH IBIBQIEIT PROJECTProjEt Caunnts bs Yar

Totals Iwcludini Cwiowncius Tots Including Cotinocius(Dblo w OO (UH U00

n1995119 6 1991/137 1997/lYB11l99w1m 199W19 latal 1985/196 19191897 /1871"o 1 1931/19 l 9/1 Totw

A. I nT OF ILI iC WLTH ISERYIES 199M.7 6PY5M.2 79694.5 8,137.3 61,597.2 304,173.9 2,110.B 6,542.3 9,395.4 89,567. 6,503.4 32,119.73. SIUEN6UENI WHP H1917 5.107.5 4499.4 49739.1 4,137.0 1,504.0 20,396.1 539.3 517.4 5W.3 43U.9 159.3 21532.7C. SIREIIITNEIU TUAIhINI I IEC CAPACITY 6h230.0 6,500.9 2599.6 Is663.7 1,531.9 19,515.0 *7.9 686.5 273.4 175.7 161.3 1,95.1D. IIERlU'IEIT OF 5 UPlY SYSTE1 6,276.8 19I,68.3 40r216.4 21t419.0 - 97.950.5 662.B 2I109.6 4,254.1 2,261.3 - 9,297.3

Totl PROJECT MSIS 37,604.0 934323.6 127,117.7 109,357.1 U44623.1 431,25.5 3.970.9 9,954.7 23,423.2 11,442.1 6,34.0 45,514.8_===== := _ _ = 9 _ 1 93 2

April 19, 1Y95 15:N

- 91 -

Minex ITabla 1.3

_ceaLTN FRESIFT PIRC

Samw Avamt by ProjKt Com_ent

PhnicalUEVLCPUET F TUHEHSlBIE DEEL'PEHY WF Cant nyAinMNAIC HEATHI STR IEIIIMI TUAINIE AIAD IEC MU SUPPLY - -

SERVICES ONH llAMT CACITY s1s Total I _Ant-- UU aa_ ___. _. .sa-us- n=ua . inaa su. ussa...as,

1. INVESTIIET CGSTS

A. CIVIL gm3125

1. PRIDMT IALTH FACILIES

NEW CONSTRUCTION 50h751.2 - - - 5O0751.2 10.0 5,075.1UPGRADING AN REPAIRS 14319.5 - - 14,319.5 10.0 1I432.0

Sub-Total PRIMARY HEALTH FACILITIES 65,070.7 - - - 65,070.7 10.0 6,507.12. WITSP.TL FACILITIES

MEN CDTRUCTIOK l5v93.2 - - - 15.9.2 10.0 1i599.8UPWIIING AND REPAIRS 15,340.1 - - - 159340.1 10.0 1534.0

Su-Total NHSPITAL FACILITIES 31.338.3 - - - 32,338.3 10.0 3,133.13. DRLI SUPPLY STSTEN - - - 20*672.0 20*672.0 10.0 2,067.24. SUPERVISIEI AM ARCHITECT FEES 4v820.5 - 79229.3 12.D49.9 10.0 1.205.0

Sub-Total CIVIL HlIRS 101,229.5 - - 27,901.3 129,130.9 10.0 12P913.11. EWUIP10T

PRILUT HEALTH FACILITIES 10,410.0 - - - 10,410.0 10.0 1,041.0HOSPITAL FACILITIES 20P815.9 - - - 20,115.8 10.0 2,031.6DRUG SUPPLY SSTEIM - - - 20,440.7 20O440.7 10.0 2,044.1PRINTING An AIDIO - VISUAL - - 2*105.5 - 2.105.5 10.0 210.5PUBLIC HALTH CMLLEGE OF RANT - - 5,025.0 - 5,025.0 10.0 502.5RESEARCH ACTIUITIES - 3.135.6 - - 3,135.6 10.0 313.6RDJECT ADINISTRATIO - 502.5 - - 502.5 10.0 50.3

b-T-lotal EMUINENT 31,225.8 34639.1 7130.5 209440.7 629435.0 10.0 6,243.5C. FURLITIRE

n114RIT EALTN FCILITIES 3,304.8 - - - 8,304.8 10.0 B30.5HOSPITAL FACILITIES 2.362.6 - - 2.362.6 10.0 236.3PROJECT AIIISTRaTION - 153.7 - - 153.7 10.0 15.4

Sb-Total FUiITUK 10,667.4 153.7 - - 10,921.1 10.0 1.062.1D. MATERIAL AND SUPLIES - - 1.561.8 11,912.3 139494.1 10.0 1,349.4E. VEHICLES

PR11Y HEALTH AM HWITSL FCILITIES 3,564.2 - - 9,564.2 10.0 856.4MUG SuPLY SYSTEM - - - 502.5 502.5 10.0 50.3AUDIO - uISuL - - :.s - 2,577.3 10.0 257.3PU8LIC HETH COLLEGE OF RABNT - - 502.5 - 502.5 10.0 50.3RESERCH ACTIVITIES - 542.7 - - 542.7 20.0 54.3PROJECT NIIINISTRATION - 241.2 - - 241.2 10.0 24.1

Sub-otal UEHICLES ,564.2 703.9 3,0a0.3 502.5 129130.9 10.0 I,292.1F. TEONICAL ASSISTICE

LAL EXPERTS - 4,699.2 - - 4,699.2 5.0 235.0FOREIGN EXPERTS - 2,M.1 - 3,445.0 6.220.1 5.0 321.0

Sib-Total TEDlEICAL ASSISTMIE - 7,474.3 - 3,445.0 10,919.3 5.0 54.0G. ERSES 7RAIIIG - 1,219.7 745.4 576.0 2,541.1 0.0 0.0H. TRAINING SE1111RS

IIS. TtElRAINING SERIMS - 402.3 201.7 31.1 62.6 0,0 0.0REGIEtL TRAININ SEHINARS 1,566.4 - - - 1,560.4 0.0 0.0

Sib-ot alU TRAIG SEMINARS 1,561.4 402.8 2e.7 51.1 2.2l1.0 0.0 0.01. PU PREPATIM FACILITY - 710.3 - - 710.3 0.0 0.0

Total IINE5T1EN8 cUs 153t25.2 4302.-8 122746.6 64,129.0 245,213.5 9.6 23,427.2

- 92 -

Annex I

NmROCCO Table 1. 3WALTm KMWMmc ioaC' (cont'd)

Summ Acart bi PnJut Comment(KM i 1001

IEUIPIET F STE)REN1IE EIIAT OF ContinenciesMC EALTH STENETIOX TRAINING MmS EC N5 SAPPLY

RlUICES MAPFI MAN CAPACITY SYSTE Total z burt

II. RECLRRENT COSTS

1. TIREE PRVINCES

SLMxIES OE INCRErmAL STAFF 21.0M3.1 - - - 21,093.1 0.0 0.0DRUGSiP EDICAL GAFIES 29,591.6 - - - 29591.6 10.0 29959.2FUEL AND VEHICLE OP AND MINTEIWE 6998.4 - - - 6,986.4 0.0 0.0TRAVE SUISISTANCE 5t456.8 - - - 5,456.8 0.0 0.0OFFICE SPPLIES 1W349.6 - - - 1,349.6 0.0 0.0SANITATION SUPPLIES 1.626.8 - - - 1,626.8 0.0 0.0

Sub-Total THREE PROVINCES 66.004.2 - - - 66.004.2 4.5 29959.22. PIM STAFF IN RAT

FUEL AND VEHiCLE OP. AND HAINTWNCE 211.1 - - 211.1 0.0 0.0TRAWL SA3SISTANCE - 265.0 - - 265.0 0.0 0.0TRAWEL COST (AIR) 95.4 - 95.4 0.0 0.0

Sub-Totl PID STAFF IN RANT - 571.5 - - 571.5 0.0 0.03. RESEARCH ACTIVITIES

FUEL AD VEHICLE OP. ND NAINTECE - 422.1 - - 422.1 0.0 0.0TRAWL SUISISTANCE - 212.0 - - 212.0 0.0 0.0TRAWL COSTS (AIR) - 265.0 - - 265.0 0.0 0.0OFFICE SUPPLIES - 165.2 - - 165.2 0.0 0.0

Sit-Total RESEARCH ACTIVITIES - 1,064.3 - - 1,064.3 0.0 0.04. TRAINING AND IEC

FUEL C EIICLE OP. AMN MINT. - 1,939.7 - 1.939.7 0.0 0.0

Sut-Total TRAINING AND IEC - 1.939.7 1939.7 0.0 0.0

Total RECIRRENT COSTS 66i004.2 1.635.8 1P939.7 - 6957.6 4.3 29959.2Total BASELINE COSTS 21S9259.4 l16018.5 14686.3 64829.0 314,793.1 8.4 26'386.3

Pihsical Cantiniencies 18.127.8 B31.3 19179.3 6P247.9 26,386.3 0.0 0.0Price Contingencies 66876.7 3P536.3 2,649.5 169873.6 99,846.1 7.6 6h843.6

Total PROJECT COSTS 3049173.9 20,386.1 15.515.0 979950.5 431,025.5 7.7 33v279.9s . ~~~~~~~~-~=Z= S t=wS=S== ZX= t== 3=-: -:===:_=

Tas 509627.8 29090.7 3377.8 1192M3.7 67.390.0 9.7 5,835.1Foreign Exchan 1399601.7 109771.9 12i877.2 -:9742.4 219,93.2 9.3 18.272.0

April 19, 199M5 155:

-93-Anab I

Table .4

IEILTH IIE!NT PROMEmmCM uTS T WAYv

(DD m0) 1 '(lU ) I TotalS Foeign Bu

Local Fomi Tota Local Foritih Total Eads Costs

I. IESTNR COSTS

A. CIVIL IMES

1. MN41WALTN FACILITIES

IEn NUCTION 319022.3 19,728.9 50,751.2 3,275.9 2,013.3 5,359.2 39 16IFUDIE AN REAIRS 1,753.0 5,566.5 14.319.5 924.3 537.1 151.1 39 5

Sub-TLotl M11W ELT FACLIk ES 399775.3 25,295.4 45,070.7 4200.1 t2671.1 69371.2 39 212. WI3T5 L FAILITIES

EUI CUST3ICTION 9,779.1 6,219.1 15,9".2 1.032.6 6il. 1,09.4 39 519345 AnD REMISS ,376.8 5,963.3 15,340.1 90.2 629.7 16191.9 39 5

Sub-Total HOSPITAL FACILITIES 19,155.9 12,182.4 31,30.3 74022.8 1,26.4 3,309.2 39 103. IRIE SIUPL SISTER 12.636.0 9.036.0 20O.62.0 1u334.3 948.6 2182.9 39 74. SUPERVISION AD ACITECT FEES 7.277.6 4,M.2 12,049.3 761.5 503. 1,M.4 40 4

Sb-Total CIVIL EkS 78,344.9 50.25.9 129,130.8 1,325.3 5,310.0 13,635.8 39 413. EUIIIENIT

PRINST WEL.TN FACILITIES 2,0Q.0 9,32B.0 10,410.0 219.9 979.4 1,079.3 Be 3IWSITAL FACILITIES 4,163.2 16,652.6 20,15.8 439.6 ,5.S 2,193.1 so 7RU SUPPLY SISTEN 4,0U8.1 l6.352.6 20,440.7 431.7 1726.3 2151.5 go 6

PRIN111 AD AMUI0 - VISIUL 421.1 1,64.4 2105.5 44.5 In., m.3 90 1PIILIC INALTY COILLEE CF IWAT 1,005.0 4.020.0 502e.O 106.1 424.5 530.6 B0 2RESEECH ACTIVITIES 627.1 2.5O.5 3.M35.6 66.2 264.? 331.1 90 IPROJECT ADHINISTTIOh 100.5 402.0 502.5 10.6 42.4 53.1 9o 0

Sub-Totl E0NUPENT 12,487.0 49,948.0 62,435.0 19318.6 ,74.3 6,592.9 so 20C. FMIITUIE

PMW HEAILHN FACILITIES 3,323.7 4,481.1 9,304.3 403.8 473.2 n77.0 54 3NOSPITAL FACILIMES 1,087.9 l2748. 2362.6 114.9 134.6 249.5 54 1PROJECI ADIINISTRATION 70.7 12.9 153.7 7.5 8.8 16.2 54 0

Sub-Total FIIITUE 4,n.3 5t313.8 10,321.1 526.1 616.6 2,142.7 54 3D. MTERIAL S sULIEs 2.346.1 10,643.0 13,494.1 300.5 1,124.4 1,424.9 79 4E. VEHICLES

PRIHAR" IENTH AND HOSPITAL FACILITES 2,569.2 5,974.9 3.564.2 271.3 633.0 904.3 70 3ua SUPL SISTER 150.3 351.9 502.5 15.9 37.1 53.1 70 0

A1310 - VISUAL 773.3 1,304.5 2tW.7. 31.7 190.5 27.2 70 1FSIC HALTH CLIE IF AAT 150.8 351.8 502.5 15.9 37.1 53.1 70 0IESE4IN ACTIITIES 162.8 379.9 542.7 17.2 40.1 7.3 70 0PROJECT AIHIaISTRnAnoN 72.4 168.8 241.2 7.6 17.8 25.5 70 0

Sub-Total VEHIES 3.39.3 9051.6 12,930.9 409.6 99.8 1,365.5 70 4F. TEC0IC4L ASSISTIMCE

LIAL EXPETS 4.475.3 223.4 4,699.2 472.6 23.6 46.2 5 1FIIIEI EXERTS 652.5 5.57.6 69220.1 68.9 587.9 6568 90 2

Sat-Totl TlV ASISTMEE 5-12.2 sM.1 10,9%9.3 541.5 611.5 1,153.0 53 3S. IIAS T1I1U0 - 2.541.1 2,541.1 - 268.3 2633 100 1HN. 1111 SlIMS

3TIUE. 1I"= 5EI_S 471.2 191.5 642.6 49.8 20.2 70.0 29 0REUSE TJEINS 93MS55 1.115.2 453.2 15Y84 117.8 47.9 165.6 29 0

Su-Total TR1I35N SOIMS 1.536.4 644.6 2,231.0 17.5 U.1 235.6 29 1I. PUS TIUII FELMU 234.1 426.2 710.3 30.0 45.0 75.0 60 0

Totl IEIIIT WTrs Il1.31.3 135175.3 2413.35 11.6619.7 :4.74.1 MOW93. 55 73

- 94 -Annex ITable 1.4

- (cont' d)

su c camsue(BW11 '000) (USI '000) Z Total

-- - ------- I Foreinm 3wLocal Formi Total Local Forein Total Exchmu Costs

aun i uZnu= __a 9 a i a aa u

II. RECUIRENT COSTS

I. THREE PROVINCES

SALARIES F INCREENTAL STAFF 21,093.1 - 21,093.1 2t227.4 - 2.227.4 - 7[tUG AND MEICAL SUPPLIES 11,974.4 17,617.2 29t591.6 19264.5 1,960.3 3,124.8 60 9FUEL AND VEHICLE P AND MAINTENANCE 1:377*3 M50M.1 698U6.4 145.4 581.7 727.2 so 2TRAVEL SUBSISTANCE 59456.9 - 59456.8 576.2 - 576.2 - 2OFFICE SIPPLIES 824.1 525.5 19349.6 87.0 55.5 142.5 39 0SANITATION SUPPLIES 996.1 630.7 1,626.8 105.2 66.6 171.8 39 1

Sub-Total THREE PROVINCES 41.721.7 24P282.5 669004.2 4t405.7 2,564.2 6,969.8 37 212. PIU STAFF [N RABAT

FUEL AND VEHICLE OP. AND MAINTENANCE 42.2 168.8 211.1 4.5 17.8 22.3 80 0TRAEL SUDSISTANCE 265.0 - 265.0 28.0 - 28.0 - 0TRAVEL COST (AIR) 95.4 - 95.4 10.1 - 10.1 - 0

Stub-Total PIU STAFF IN RABAT 402.6 168.8 571.5 42.5 17.8 60.3 30 03. RESEARCH ACTIVITIES

FUEL AND VEHICLE OP. AND MAINTENANCE 84.4 337.7 422.1 8.9 35.7 44.6 80 0TRAVEL SUOSISTANCE 212.0 - 212.0 22.4 - 22.4 - 0TRAVEL COSTS (AIR) 265.0 - 265.0 28.0 - 29.0 - 0OFFICE SUPPLIES 100.9 64.3 165.2 10.7 6.8 17.4 39 0

Sub-Total RESEARCH ACTIVITIES 662.3 402.0 19064.3 69.9 42.4 112.4 38 04. TRAINING AND IEC

FLEL AND VEHICLE UP. AND MbINT. 387.9 1,551.7 1.939.7 41.0 163.9 204.6 sO 1

Sub-Total TRAINING ND IEC 387.9 19551.7 1,939.7 41.0 163.9 204.8 80 1

Total RECURRENT COSTS 43,174.5 26.405.1 699579.6 4,559.1 29788.3 7.347.4 38 22Total BASELINE COSTS 1539212.8 161,580.3 314,793.1 16t178.8 17,062.3 33,241.1 51 100Phsical Continsencies 11,757.8 14,628.5 26,386.3 1,241.6 1,544.7 20786.3 55 8Price Continuencies 46,061.7 43,784.3 89,846.1 49864.0 4:623.5 9,487.4 49 29

Total PROJECT COSTS 211,032.3 219.993.2 431,025.5 22,284.3 23.230.5 45.514.8 51 137

Anil-- =====-- - ------ - -= -=== ---- 19--1-85---:--April 19 198 5 l:51

Table 1.5

ammnpm PROJECSuqanv Accuts bk Year

IDllllA 0002

am Costs Forrin Exchaws

I995/I9B 193W997 1997/1M9 19911969 1999/IWO Total : mo.j.tS8USu3us 33353333m SUSEUSUUU EWSSSWUE ManUaUss. SBnS.asma flUU SsUaf

1. IN1ESTIEI MsTS

A. CIVIL MS

1. PRIlRY HEALTH FACILITIES

NEU COeSTRUCTION 2P490.9 12u454.6 13,387.4 149945.5 7,472.3 50752.2 38.9 19729B.9GRING AD REPAIRS 4.:55.9 5474.4 44389.1 - - 14.319.! 3N.Y 5566.5

Sub-Total PRIERY HEALTH FACILITIES 69646.9 29,229.0 17,776.5 14945.5 79472.5 65,070.7 38.9 25,295.4. HOSPITAL FACILITIES

NEM CONSTRUCTION - 2,759.7 2.759.7 7,079.27 3.39.6 15999m.2 38.9 6,219.1UPGRADING AND EAIRS - 4,660.8 5,206.9 2,680.4 2,792.2 15 340.1 39.9 59963.3

Sub-Total HOSPITAL FACILITIES - 7,420.5 7,966.5 9,759.6 6,291.7 31.338.3 3S.9 12.182.43. IIO SIUPLY SYSTEM 2.0467.2 8268.8 109336.0 - - 20U.72.0 U3.v S.036.04. SUPERVISION AD ARCHITECT FEES 29954.7 4v649.1 2.527.5 1.235.3 683.2 12P049.B 39.6 4,772.2

Sub-Total CIVIL VORKS 1l1668.8 39s567.4 38t60f.5 25,940.4 14.347.7 129i130.8 38.9 50295.9D. EOUIPNENT

PRIANKY HEALTH FACILITIES 520.1 3. 122.1 3.197.6 2,556.2 1.012.0 10,410.0 90.0 8.328.0HOSPITAL FACILITIE - 2u518.5 B.420.7 5,196.4 4t480.2 20.Bis.8 50.0 16,652.6BRU6 SUFPtY SISTER - 29044.1 16.352.6 29044.1 - 20.440.7 80.0 16,352.6PRINTING D OADIO - VISUAL 589.6 926.7 589.1 - - 29105.5 80.0 1,684.4PIUBLIC HEALTH COLLEGE OF RABAT 31015.0 2010.0 - - - 5.025.0 80.0 4,020.0RESEARCH ACTIVITES 778.9 773.9 C29.l 748.7 - 3v135.6 80.0 2*50B.5PROECT AIINISTRATION 251.3 251.3 - - - 502.5 90.0 402.0

5t-Total EQUIPMENT 5.154.8 11,651.5 29.589.1 10.547.4 5.492.2 62435.0 50.0 49.949.0C. FURNITLRE

PRIAR HEALTH FACILITIES 622.0 2v771.6 2.5375.7 IB,68.1 507.4 8t304.8 54.0 4,481.2HOSPITAL FACILITIES - 179.1 702.7 456.2 1.024.6 2u362.6 54.0 1.274.8PRDJECT ADHINISTRATION 30.7 30.7 30.7 30.7 30.7 153.7 54.0 02.9

Sub-Total FIINITURE 652.7 2.991.4 3v269.2 2,355.1 19i562.7 I0.821.1 54.0 5,83B8.D. MATERIAL AND SUPPLIES 158.2 158.2 474.5 124386.9 316.4 139494.1 75.9 10.648.0E. VEHICLES

PRINRY HEALTH MD HOPITAL FACILITIES 1.678.4 1.455.5 1.678.4 2,517.6 839.2 B.564.2 70.0 5.94.9DRUC SUPY SYSTEH - 201.0 201.0 100.5 - 102.5 70.0 351.9ADID - VISUAL I203.0 1.203.0 171.9 - - 2.577.8 70.0 1a804.5ULIC HEALTH COLLEGE OF RANT 301.5 201.1 - - - 502.5 70.0 351.8

RESEARCH ACTIVITIES 168.8 217.1 156.8 - - 542.7 70.0 379.9ECT ADrINISTRATION 160.8 - 80.4 - - 241.2 70.0 168.8

Sub-Toal MEHICLES 3!412.5 3@672.5 2.2B8.5 29618.1 839.2 12t930.9 70.0 99051.6F. TECDICAL ASSISTANCE

LOCAL EXPEIRTS 1.032.0 1:.22.3 :.06.7 IOO.2 298.1 4.69.2 4.9 223.4FOEIGN EPERTS 1.210.! 2.167.5 1,706.1 866.0 267.9 6.220. 89.5 5,567.6

Sub-Total TECICAIL ASSISTANCE 2.242.5 3v3B9.7 2.774.B 1946.2 566.0 10.91. 53.0 5-791.15. OVESEAS TRAINING 355.9 745.4 677.6 474.3 298.0 2.541.l 100.0 2.41.:H. TRAINING SEIINS

NATIONL TRAININ6 SENINS 132.9 150.1 200.2 137.6 41.7 662.6 29.9 191.5REGINL TRAINING SEINARS 470.5 313.7 313.7 235.3 235.3 1 568.4 29.9 453.2

Sub-Total TRAINING SEIERS 603.5 463.7 513.9 372.9 277.0 2.31.0 B2.9 644.6I. PRJECT PlPOTIDN FACILITY 710.3 - - - - 710.3 60.0 4-6.2

Tot INVESTINIT COSTS 25,059.0 61s629.8 7B.194.1 56,641.3 23.489.2 245.213.3 55.1 135,175.3

-96 - Annse ITable 1.5(cant 'd)

NEALTN UEVELWENT PROJECTSumrv a 1 ts bi Year

(low '000)

mu Cots Foreign Exchane

1 15N 19161l"7 1"7/19 1998/99 199/19M Total z Amountwn..u u a . u .a uu.. ... . ........ a ...... mongooses ..... sound ..a..a...

II. RECURRENT COSTS

1. THREE PROVINCES

SMRIES OF INCREMENTAL STAFF 1,123.3 3,156.4 59335.9 59738.7 5.73B.7 21093.1 0.0 0.MMU6 AD IEDICAL SULIES 3,S42.1 4,854.5 5,504.0 7M.6 8 852005. 29,591.6 59.5 17,617.2FUEL AN VEHICLE OP AND MAINTENANCE 694.1 1W158.2 1,678.0 1.679.0 14678.0 6,986.4 80.0 S,509.1TRAVEL SUISISTANCE 903.5 1,178.4 1,138.0 19096.7 1,140.1 5.456.B 0.0 0.0OFFICE SUPPLIES 221.1 257.9 273.1 299.8 298.9 19349.6 38.9 5.25.5SANITATION SUPPLIES 325.4 325.4 325.4 325.4 325.4 1,626.6 3E.6 630.7

Sub-Total THREE PROVINCES 6,909.4 10930.7 14,254.4 16#823.4 17,106.3 66.004.2 36.9 24,928:.2. PIU STAFF IN RABAT

FUEL AND VEHICLE UP, AND MAINTENANCE 50.3 50.3 50.3 30.2 30.2 211.1 a0.0 1o8.8IRANtL SUISISTANCE Ss.o 53.0 S3.0 >2.0 53.0 265.0 0.0 0.0TRAVEL COST (AIR) 21.2 2!.2 21.2 15.9 15.0 9!.4 0.0 C.0

Sub-Total PIU STAFF IN RANT 124.5 124.5 124.5 9vs, 9.1 S71.5 :9.5 169.83. RESEARCH ACTIVITIES

FUEL AND VEHICLE OP. AND MAINTEANCE 84.4 84.4 84.4 04.4 94.4 4 :.1 90.0 337.'TRAVEL SU3SISTANCE 42.4 42.4 42.4 42.4 42.4 21. 0.0 0.0TRAVEL CSTS (AIR) 53.0 53.0 53.0 ;3.0 Z3 0 :265.0 0.0 3.0OFFICE SUPPLIES 33.0 33.0 33.0 33.0 33.0 165.2 38.9 o;.3

Sub-total RESEARCH ACTIVITIES 212.9 212.9 212.9 11 21:.Q lo4.3 37.8 40:.G4. TRAINING AND IEC

FUEL AND VEHICE OP. AND IAINT. - 484.9 484.9 484.9 494.9 1.439.7 60.0 1291.'

Sub-Total TRAINING AND IEC - 484.9 404.9 484.9 494.9 1,939.7 80.0 1SS1.

Total RECURRENT COSTS 7,146.7 11,752.9 15,076.6 17,620.3 1,.983.1 6M7'9.6 37.9 :6,405.1Total BASELINE COSTS 32,205.8 73,382.7 939270.8 74,261.6 41,672.3 3144793.1 !I.3 1w19C.3Physical Contm csias 2.81.0 6W358.0 3111.9 60250.7 3.084.6 26.86.3 5S.4 14625.5Price Contrmncits 2417.1 13.582.8 25735.0 27,044.6 1898. 99846.1 48.7 43,794.3

Totl PROJECT COSTS 37.604.0 939323.6 1279117.7 1089357.1 o6213.1 431,025.5 51.0 :19M9'3.:- .......... .|ssa.s -t-aan .............. -wssralt.. .- t.... "s-m asa ...... .s-as- - .........

TAcus 6,.27.4 14905.2 20,79.7 14,336.4 1C9571.4 679390.0 0.0 0.0Fotuian Exchag 19.158.8 449940.4 67,468.4 589M,1.2 29.654.4 219,93.: 0.0 0.0

bril 19, IM 15:41

* -- - -- -- - -- - - - - -@- -- - - -- - -- -- - -- - -- - -- -

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- 98 -

Anmez KPage 1 of 2

MOROCCO

RIALTH DZVEOPMWT PROJECT

8elected Documets and Data Availablein the Proiect File

Sectiou & General reports on Morocco and population. Health and nutritionsectors.

A-I Ministry of Public Health, "Eaquite d'opinion our la planificationfamiliale", 1971.

A-2 USAID, "Morocco: Food Aid and Nutrition Education", August1980.

A-3 "D&finition des *edicaw.ats de base pour la circonscription",Rabat, 1981.

A-4 Alaoui, Mechbal, "La sant& au Maroc en l'an 2000", Rabat,1982.

A-5 Alaoui, Mecbbal, "La sante publique".

A-6 Ministry of Public Healtb, Directorate of Technical Affairs,"Kenseignewents &pidlmiologiques", 1981-82.

A-7 APHA, "INC for Family Planning in Morocco", 1980.

A-8 APH&, "Family Planning Manpower Development", 1980.

SectiQon: General reports and studies relating to the project.

1-1 Ministry of Public Health, "Projet de d&veloppeoent des servicesde aant& dans lea provinces d'Agadir at Settat: Plan d'op&ration,rapport compl&mentaire 1981; Budget programe (1982-83)".

5-2 VRIOIUMM, Premier r auort d ivjluatiou, 1983.

3-3 Casparetto, laDuort PXAR3I, 1983.

3-4 Ministry of Public Health, 'Donnies d4&ographiques de Settat",1983.

3-5 T. Amt. M. Combes, RaDort de mistion aour a uDi *U oroietde *oins de *t& de base, CLEAR, July 1983.

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Annex KPage 2 of 2

B-6 Ministry of Public Health and CINAN, "Rapport int&rimairede preparation", June 1983.

3-7 Ministry of Public Health, "Project Preparation Documents",1984.

B-8 Ministry of Public Health, "VDMS, Resuu e succinct, Marrakech",December 1978.

B-9 USAID, "Final Evaluation of VDMS", December 1983.

B-10 Ministry of Public Realth, "Health Development Project - Proposaldocuments No 1 to 14", Rabat, 1984.

Section C: Selected working papers prepared by Bank staff and consultants.

C-1 C. Pierce, "Morocco: The Demographic Situation', 1978.

C-2 S. Basta, "The Nutrition Situation in Morocco". 1981.

C-3 C. Pierce, "The Health Situation", 1978.

C-4 SCET-AGRI for the World Bank, "Morocco: Health Risks Evaluation",March 1984.

C-5 J. Andreu, "Morocco Health Sector Financial Analysis", 1983.

C-6 "Training of Paramedical Manpover for Family Health and FamilyPlanning", March 1979.

C-7 J. Pillet, "Morocco Drug Supply and Utilization", 1984.

C-8 Hank Schut, "Morocco Drug Supply", 1984.

C-9 Hank Schut, 'Drug Supply Follow-Up Report", 1984

C-10 J. Lecomte, 'Le planning familial au Maroc", 1984.

C-ll WHO/EURO, "Education pour la sante", 1984.

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