Report No. PIC4329
Project Name             Guinea-Bissau-National Health Development Program (@
Region                           Africa
Sector                           Health
Project ID                       GWPE35688
Borrower                         Government of Guinea-Bissau
Implementing Agency              Ministry of Public Health
Bissau, Guinea-Bissau
FAX: (245) 20-17-01
Date this PID Prepared           September 16, 1996
Date PID Revised                 July 7, 1997
Appraisal Date                   June 23,1997
Projected Board Date             October 28, 1997
Sector Background
Guinea-Bissau's population of 1.1 million has extremely high rates
of mortality and morbidity, even by African standards. Infant
mortality is estimated at about 140 (and even higher in certain
areas of the country) per thousand live births. Child mortality
under 5 years of age is estimated at over 240 per thousand.
Immunization levels are low, with only 45% of children immunized
against DPT by their first birthday. Sanitation, including basic
latrines, is available to less than one third of the population.
Malaria is the main cause of morbidity recorded and the leading
cause of infant deaths. Severe diarrhea is the second cause of
infant deaths and the third cause of death for the whole
population. The prevalence of STDs is estimated at 25 percent among
adults, and prevalence of HIV2 among adults is about 10%, the
highest in the world. Although the HIV1 epidemic, is much more
recent, about 1% of the adult population living in the regions of
Bafata, Cantchungo and Gabu are now HIV1 positive. A resurgence of
tuberculosis (TB) has already been noted in Guinea-Bissau. The
number, composition and uneven geographical distribution of health
personnel, as well as low civil service salaries and the lack of an
incentive system, are growing concerns; there are serious shortages
of nurses, auxiliary nurses, midwives, and laboratory technicians,
and there is a surplus of doctors in the capital but a deficit in
the regions. The present level of funding is inadequate to sustain
even a minimal volume of health care for health problems with the
highest priorities. Moreover, the allocation of available resources
among health facilities and people throughout the country is not
appropriate. The Ministry of Public Health, with support from WHO,
the Netherlands, the Bank and other agencies, is completing
preparation of a National Health Development Plan--1997-2001, which
will permit improved allocation and more effective use of both
government and donor-supplied resources. The major health sector
donors and technical agencies in the country agree with the



Ministry of Health that emphasis needs to be placed on
strengthening and integration of the health services system, with a
strong focus on widespread, effective coverage of the population
with a package of high impact, cost-effective basic level services.
Project Objectives
The overall objective of the National Health Development Program
(NHDP) is to improve the health status and well-being of the
population, particularly women and children, through a
strengthening at all levels of the national health system,
including health services and facilities, and management structures
and processes. Specific objectives are: (i) to increase the use and
effective coverage of primary health care services and referral
centers so that by the end of the Program the percentage of health
centers which are operational will be at least 85%, the percentage
of children less than one year correctly immunized with DTP3 will
be at least 90-, and the percentage of births safely attended by
trained midwives will be at least 80- (ii) to strengthen the
institutional capacity at all levels; (iii) to improve the quality
and the management of human resources, with the staffing of health
facilities with adequately trained personnel; and (iv) to reinforce
intersectoral coordination and action in health-related activities
in order to promote better health among the population.
Project Description
The project, in parallel to the National Health Development
Program, would have four main components or categories of activities:
(1) Utilization and coverage of Primary Health Care Centers
and Referral Centers. The program will provide a basic minimum
package of cost-effective, integrated, preventive and curative
health services in health centers accessible to a majority of the
population, with community outreach and with effective support and
supervision by regional health (health district) teams. Central
support and supervision, now provided through national programs
(e.g., AIDS, EPI, MCH, FP), will be coordinated at the national
level and integrated at the regional and peripheral levels.
Emphasis will be on system and service integration and
decentralization, and on rural and marginal urban areas.
(2) Strengthening of Institutional Capacity at all levels
(central, regional and local). The program will: (i) at the central
level, improve program planning, implementation, monitoring and
evaluation, supervision, administration and financial management
(including the development of an Integrated Health Sector
Information System), and the procurement and distribution of
essential drugs, with special emphasis on the preparation and
monitoring of annual work programs and budgets for the NHDP
(expected to be a rolling two-year plan within a defined longer-
term framework of five years). (ii) at the regional and local
levels, the program will enable health services and facilities to
function properly following the decentralization of health care
services and their management.
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(3) Management and Development of Human Resources. Through
this component, the project will improve working conditions;
support the Directorate of Human Resources and Organization (DRHO)
training institutions; and expand in-service training.
(4) Promotion of better health. The program will strengthen
intersectoral coordination of health-related activities. These
activities will involve the private sector and NGOs.
Project Financing
The IDA credit will finance less than 20% of the total project
cost, with an estimated foreign cost of US$6.5 m, and a local cost
of US$2.5 m. The Government will finance about 25% of the total
project cost. The Dutch have expressed interest in cofinancing
essential drugs and training. The WHO is already helping government
with training on general planning and management and on
decentralization, as well as providing AIDS program support. Other
donors include the African Development Bank, the European Union
(with a focus on IEC activities and budget management), France (for
STDs), USAID (through the NGO Africare with a program to support
HIV-infected persons), China/Taiwan (for drugs and support for
Cacheu region health services), and Portugal. Finally, a Japanese
grant of $320,000 and a Bank PPF of $210,000 have already been
provided to support project preparation.
Project Implementation
The Ministry of Public Health, through its directorates and line
agencies, will have overall responsibility for management of all
program activities. The General Directorate of Public Health and
its various directorates (the Directorate of Human Resources,
regional health teams, health centers, referral centers and
specialized institutions) will be responsible for all operational
aspects of the program. The General Directorate of Planning and
Cooperation (DGPC) and its various directorates will be responsible
for planning, monitoring and evaluation, administrative and
financial management, and the coordination of external assistance.
The DGPC will be strengthened by the addition to its staff of a
public health specialist, a health economist, an expert in
accounting and financial management, and a program coordinator. The
Program Coordinator in particular will assist the newly created
Directorate for the Coordination of External Assistance in DGPC to
ensure that everything is done by the responsible directorates of
MOPH to comply with the requirements of all donors regarding
procurement, disbursements, accounts, audits, progress reports, and
annual and mid-term reviews. The role of all directorates of MOPH
in the implementation of the program, and the relationships between
them, will be detailed in the Program Implementation Manual under
preparation (the finalization of that manual is a condition of
effectiveness of the IDA credit).
Project Sustainability
The sustainability of the program will be helped considerably by
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the sector approach and the close coordination envisaged among the
key donors. Other factors which would help are: (a) ability of
Government to accept to redefine its role and provide continuous
support to the regions; (b) use of beneficiary assessments for
yearly reprogramming; and (c) transparency in allocation and
management of resources.
The eventual sustainability of services is enhanced by emphasis on
basic primary health centers, with regional (equivalent to
districts) hospitals for referral services, appropriate training
and use of mid-level health personnel, redeployment of existing
resources, provision of generic essential drugs, community
participation and cost recovery, and strengthened management
support and supervision. NHDP's integration of present vertical
programs (e.g., Immunizations, IEC, AIDS, STDs, Tuberculosis,
Leprosy), and the corresponding greater budget flexibility, will
increase overall efficiency. The program's essential drug financing
will contribute to the MOPH's planned expansion of the Bamako
Initiative, and cost recovery, particularly in hospitals, is
incorporated in the NHDP. Beneficiaries and regional health teams
have been involved in the program's design. Beneficiaries will
participate in implementation, monitoring/evaluation and adjustment
of the NHDP, through participatory evaluations of program activities.
Lessons Learned
Lessons learned from previous IDA projects in the health sector in
Guinea-Bissau suggest that more attention needs to be given to the
MOPH's implementation capacity which tends to be weak, to the
availability of local funds which tend to be insufficient, and to
donor coordination which tends to be problematic. Lessons learned
from health project experiences in general indicate that vertical
programs are unsustainable, that it is possible to improve overall
efficiency by program integration, and that a basic package of
cost-effective health services (requiring the presence at the base
level of a number of critical elements including trained personnel,
essential drugs, and support from the next levels) can contribute
to improving the health status of the population. All these lessons
have been taken into account in the design of the National Health
Development Program (focus on institutional strengthening, the
integration of health services, a better allocation of human and
financial resources within the sector, appropriate technical
assistance, and a better coordination among donors). Flexibility on
the part of IDA allowing yearly reprogramming of resources for the
health sector to better accomplish the program's objectives and to
contribute to a longer term and broader view of the sector's
support and development will be especially important under the
NHDP. In addition to being more responsive to borrower needs, it
will also contribute to improved donor coordination.
Poverty Category
The proposed project woul be sector-wide and address the entire
population, so it is not part of the Program of targeted
intervention. However, it aims to provide accessible and quality
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health services with emphasis on the women and children, thereby
alleviating and reducing poverty.
Environmental Aspects
The project has been categorized as Environment assessment Category
C since no environmental risks are foreseen. On the contrary,
promotion of hygiene is expected to have a positive environmental impact.
Program Objective Categories
The proposed project responds to the human resource development and
poverty alleviation objectives of the Government. It falls 100l
under the HB (Basic Health) Category.
Contact Point:           Public Information Center
The World Bank
1818 H Street N.W.
Washington, D.C. 20433
Telephone No.:   (202) 458-5454
Fax No.:   (202) 522-1500
Note: This is information on an evolving project. Certain
components may not necessarily be included in the final project.
Processed by the Public Information Center week ending July 11, 1997.
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