Document of THE WORLD BANK Report No: 18397-GUI PROJECT APPRAISAL DOCUMENT ON A PROPOSED CREDIT IN THE AMOUNT OF SDR 8.5 MILLION TO THE REPUBLIC OF GUINEA FOR A POPULATION AND REPRODUCTIVE HEALTH PROJECT October 26, 1998 HUMAN DEVELOPMENT II AFRICA REGION CURRENCY EQUIVALENTS (Exchange Rate Effective February 1998) Currency Unit = Guinean Franc US$1 = FG1,000 FISCAL YEAR January 1 to December 31 ABBREVIATIONS AND ACRONYMS APL Adaptable Program Lending ASSFEGMASSI Association Femmes Guineennes contre les Maladies Sexuellement Transmissibles et SIDA BCPS Bureau de Coordination Population - Sante BEPR Bureau de Programmation, Etudes et Recherche CBD Community Based Distribution CERREGUI Centre de Recherche en Sante Reproductive en Guin& CNPRH Commission Nationale de la Population et des Ressources Humaines CYP Couple - Year Protection DAAF Direction des Affaires Administratives et Financieres DALY Disability Adjusted Life Years DHS Demographic and Health Survey DIEM Direction de l 'Infrastructure, de l 'Equipement et du Materiel DNSP Direction Nationale de la Sante Publique DSR Division de la Sante de la Reproduction ECD Early Childhood Development EPI Enlarged Program of Immunization FAMPOP Projet Famille et Population FGM Female genital Mutilation ICPD International Conference on Population and Development (Cairo, 1994) IMCI Integrated Management of Childhood Illnesses IMR Infant Mortality Rate IPPF International Planned Parenthood Federation MCH/FP Maternal Child Health and Family Planning MIS Management Information System MMR Maternal Mortality Rate MS Ministere de la Sante PHC Primary Health Care PHCO Population and Health Coordination Office PSF Population Support Fund PSI Population Services International QACS Quality Assurance of Care and Services RCH Reproductive and Child Health RH Reproductive Health SSA Sub-Saharan Africa STI Sexually Transmitted Infections TFR Total Fertility Rate U5MR Under Five years old Mortality Rate WDR World Development Report Vice Presidents Jean-Louis Sarbib and Callisto Madavo Country Director Mamadou Dia Sector Manager Nicholas Burnett Task Team Leader Slaheddine Ben-Halima Guinea Population and Reproductive Health Project CONTENTS A: PROJECT DEVELOPMENT OBJECTIVE -------------------------------------- 2 1. Program and project development objectives and key performance indicators -----------2 B: STRATEGIC CONTEXT--------------------------------------------5 1. Sector-related Country Assistance Strategy (CAS)---- - -----------5 2. Main sector issues and Government strategy - ---- -----------5 3. Sector issues to be addressed by the project and strategic choices: ---- ----------7 C: PROJECT DESCRIPTION SUNiMARY ---------------------------------------- 14 1. Project components---------------------------------------------------------------------------------14 2. Target populations and institutional beneficiaries----------- -- -5----------- I 3. Benefits--------------------------------------------------------------------------------------------------16 4. Institutional and implementation arrangements---- - ------------------16 D: PROJECT RATIONALE---- ------------------------------------19 1. Project alternatives considered and reasons for rejection: --------------------------------- 19 2. Major related projects financed by the Bank and/or other development agencies ------- 20 3. Lessons learned and reflected in the project design: -------------------------------------------21 4. Indications of borrower commitment and ownership:----------------------------------------- 22 5. Value added of Bank support in this project: ------------------- 22 E: SUMMARY PROJECT ANALYSIS ------------------------------------ 23 1. Economic ---------------------------------------------------------------------------------------------- 23 2. Financial Assessment -------------------------------------------------------------------------------24 3. Technical Assessment :---------------------------------------------------------------------------- 24 4. Institutional Assessment: ------- - - ---- ----24 5. Social Assessment: ---------------------------------------------------------------------------------- 25 6. Environmental Assessment: --------------------------------------------------------------------- 26 7. Participatory Approach: ------------------------------------------------------------------------- 26 F: SUSTAINABILITY AND RISKS----------------- -------------------------------- 27 1. Sustainability ------------------------------------------------------- -------------------------------- 27 2. Criticall Risks ---------------------------------------------------------------------------------------- 28 3. Possible Controversial Aspects:---------------------------------------------------------------------- 29 G: MAIN LOAN CONDITIONS ------------------------------------------------------ 29 H. READINESS FOR IMPLEMENTATION -------------------------------------- 31 I. COMPLIANCE WITH BANK POLICIES------- ------------------------------- 31 Annexes Annex 1: Program and Project Design Summary Annex 2: Detailed Project Description Annex 3: Estimated Project Costs Annex 4: Cost-Effectiveness Analysis Summary Annex 5: Financial Summary Annex 6: Procurement and Disbursement Arrangements Table A: Project Costs by Procurement Arrangements Table Al: Consultant Selection Arrangements Table B: Thresholds for Procurement Methods and Prior Review Table C: Allocation of Loan Proceeds Annex 7: Project Processing Budget and Schedule Annex 8: Documents in Project File Annex 9: Statement of Loans and Credits Annex 10: Country at a Glance Additional annexes: Letter of Sector Policy Map Republic of Guinea Population and Reproductive Health Project Project Appraisal Document Africa Regional Office Country Department 16 Date: October 26, 1998 l Task Team Leader/Task Manager: Slaheddine Ben-Halima Country Director: Mamadou Dia I Sector Manager/Director: Nicholas R. Bumett/Birger J. Fredriksen Project ID: GN-PE-41568 Sector: Pop. Health & Program Objective Category: Poverty Reduction Nutrition Lending Instrument: ADAPTABLE LENDING PROGRAM Program of Targeted I [X] Yes 1[ ] lNo I Intervention: Program Financing Data (US$M) Sources of Financing APLs Total Cost Government Others IDA First Phase: 1998 - 2002 12.00 0.60 0.10 11.30 Second Phase: 2003 - 2006 16.00 1.20 1.30 13.50 Third Phase: 2007 - 2010 16.00 2.00 1.80 12.20 Program Total Cost 44.00 3.80 3.20 37.00 Project (First Phase) Financing Data [] Loan [X ] Credit [] Guarantee [] Other [Specifyl For Loans/Credits/Others: Amount (US$m/SDRm): 11.3US $ / 8.5 SDRm Proposed Terms: [X] Multicurrency [] Single currency Grace period (years): 10 [X] Standard [] Fixed [] LIBOR-based Variable Years to maturity: 40 Commitment fee: 0.75 % Service charge: 0.75 % Financing plan (US$m): Source Local Foreign Total Government 0.60 0.60 Cofinanciers 0.10 0.10 IBRD/IDA 3.50 7.80 11.30 Total 4.20 7.80 12.00 Borrower: Government of Guinea Guarantor: N.A. Responsible agency: Ministry of Health Estimated disbursements (Bank FY/US$M): 1999 2000 2001 2002 2003 Annual 1.00 3.00 3.50 2.30 1.50 Cumulative 1.00 4.00 7.50 9.80 11.30 For Guarantees: N.A [] Partial [] Partial risk Credit Proposed coverage: Project sponsor: Nature of underlying financing: Terms of financing: N.A. Principal amount (US$) Final maturity Amortization profile Financing available without guarantee?: N.A. [] Yes [] No If yes, estimated cost or maturity: Estimated financing cost or maturity with guarantee: Expected effectiveness date: March 15, 1999 Closing date: December 31, 2003 Project Appraisal Doocument Project Title: Population and Reproductive Health Country: Guinea Page 2 A: Project Development Objective 1. Program and project development objectives and key performance indicators The Program The Population and Reproductive Health Program, which is started by this first phase (or project), seeks to provide support to the Government of Guinea in its efforts to improve the well being of the population, by preventing the risks related to reproductive health; preventing and reducing the occurrence of illnesses among vulnerable groups and ultimately reducing infant, child and maternal mortality rates. The program development objectives are to reduce the three major mortality rates -- infant, child and maternal, through (i) a slower population growth; (ii) safer behavior and adequate health practices and; (iii) improved reproductive and child health services. The program will be implemented in three phases, over a period of 12 years, the first phase being the present project. The program would cover approximately 75% of the population, including 2 million adolescents and young adults; 1.8 million women of reproductive age and 1 million children under five years of age. Phase I will initiate the program, set fundamental frameworks and processes, and carry out activities pertaining to top priorities among target populations. The main activities to be carried out during Phase I include sessions for advocacy targeted at three segments of population in Conakry and selected regions; health promotion by communicators and community volunteers in the same areas and mass media information campaigns; provision of funds to support grassroots activities for vulnerable groups and to implement activities in relation to RCH; renovation, rehabilitation and equipment of health facilities, and provision of training and supportive supervision to service providers and support staff in order to achieve rationalization of decentralized management; quality assurance of RCH services; prevention and treatment needs of groups at highest risk and coordination and management of Population and RCH programmes. Before the end of the first phase, triggers (outlined in the table below) will be assessed prior to the appraisal of Phase II. It will ensure that conditions to continue program implementation are warranted. The purpose of triggers'assessment will be to attest that legal, institutional, administrative and technical frameworks are in place, as elements of the required supportive environment of priority activities. Phase II will expand and consolidate activities It will progress towards the same objective as in Phase I and will include the same three components with broader scope and increased quantity. Main activities will include: expansion of advocacy to regions and prefectures for targeted segments of population and intensification of mass media campaigns; full fledged community based communication program and referral services addressing the needs of youth cohorts; funding of another batch of collaborating NGOs and grassroots activities; management and support for the delivery of family planning, obstetrical and child health services will be expanded and performed more efficiently. Quality Assurance teams will be operating in all Prefectoral Health Directorates; family planning/contraceptive services, standardized treatment of malnutrition and integrated management of childhood illnesses (IMCI) will be provided at first levels of care and referral. The surveillance, prevention and treatment of sexually transmitted infections (STI) will be more systematized and increased and the prevention of HIV/AIDS and treatment of opportunistic diseases in AIDS patients will become integral part of RH services; community based distribution and services will be promoted and developed. Project Appraisal Doocument Project Title: Population and Reproductive Health Country: Guinea Page 3 Before the end of the second phase, triggers and benchmarks (outlined in detail in table below) will be assessed, prior to the appraisal of Phase III. The assessment will aim at ensuring that systems and processes put in place have not suffered any setbacks, are benefiting from supportive environment, are accepted and integrated into routine operation. They would then be considered amenable to expansion, consolidation and sustainability. Phase III will ensure continuity and sustainability. This phase will progress towards the same objective as in Phases I and II and will include the same three components with an emphasis towards consolidation of systems and processes, and sustainability of achievements, including financing. Main activities included in this phase would tentatively aim at ensuring that: communicators and peer counselors are active in all prefectures; it will be the phase of ownership for the advocacy program by opinion/cultural leaders is near completion. Active lobbyists are reporting on progress of the effective ban of F.G.M; population and development data are desaggregated by gender, on a routine basis, and regularly reported to decision makers at all levels. This third phase of the adaptable program will ensure that volunteers and distributors in communities are able to redesign as needed, and with limited assistance, communication activities that meet their reproductive and child health needs. Gradual devolution of health programmes is completed. For activities with lower performances, consultative workshops will be carried out to analyze issues, redefine strategies and plan the required improvements Phase I years October 1998 - December 2002 Phase Purpose initiate the program, set fundamental frameworks and processes, and carry out activities pertaining to top priorities among target populations Triggers and * National and Regional Committees for Population and Human Resources are Benchmarks functional. for Appraising * Actions planned to lift legal barriers to the sale and advertisement of subsequent contraceptives completed. Phase * Action plan to enforce law forbidding Female Genital Mutilations is finalized. * Regulatory, financial and administrative guidelines of decentralization are issued and applied. * Members of QACS nominated for all regions and prefectures * Technical standards and procedures for QACS for Reproductive and Child Health are issued and applied in target areas. * A Comprehensive Plan for the Pharmaceutical Sub-sector is finalized. Expected * Endorsement of social and economic benefits of planned parenthood by at outputs and least 50% opinion leaders and decision makers. outcomes to be * At least 25% of childbirths are attended by trained birth attendants. assessed and * Contraceptive Prevalence Rate (CPR) in urban areas, condoms and monitored spermicides not included, is over 15% in 2002 during phase * At least 65% of annual operational plans are submitted and implemented on implementation time * Monitoring and evaluation system permits follow-up on implementation and on assessment of achievements in regions and in at least 65% of prefectures. Phase II Years January 2003 - December 2006 Phase Purpose Phase II will expand and consolidate activities. It will progress towards the same objective as in Phase I and will include the same three components with a broader scope and an increased quantity. Project Appraisal Doocument Project Title: Population and Reproductive Health Country: Guinea Page 4 Triggers and * National policy dialogue is based on the program results and issues that are Benchmarks identified downstream for Appraising * Decentralized line agencies have full decision making authority and subsequent accountability on the execution of programmes. Phase * By 2006, at least 50% of the communities have representatives in the management of the first levels of care and referral. * Community based Early Childhood Development (ECD) services. * Technical standards and procedures for QACS for Reproductive and Child Health are applied nationwide. Expected * Overall clients' satisfaction for Reproductive and Child Care and Services is at outputs and least at 50%. outcomes to be * High risk pregnancies reduced by 30% in 2006. assessed and * Infant Mortality rate at 100 per thousand in 2006. monitored * Nationwide CPR, condoms and spermicides not included, at 16% in 2006 during phase * 100% of annual operational plans are submitted and implemented on time implementation * Monitoring and evaluation system permits follow-up on implementation and on assessment of achievements in regions and in all prefectures. Phase III Years January 2007 - December 2010 Phase Purpose Phase III will ensure continuity and sustainability. This will include the same components with an emphasis towards consolidation of systems and processes, and sustainability of achievements including financing. Triggers and * Reduction of natural population growth: from 2.8 % in 1997 to 2% by 2010 Benchmarks Crude Birth rate: from 4.1 % in 1997 to 3.3% by 2010 for Appraising Total Fertility Rate (TFR) from 5.7 in 1997 to 4.2 by 2010. subsequent * Changes in opinions about reproductive health and safer health practices. Phase * Infant Mortality Rate (IMR) brought from 136.3 in 1997 to under 100 per thousand by 2010 * Maternal Mortality Rate (MMR) brought from 666 in 1997 to 350 per 100 000 live births by 2010. Expected * Overall clients' satisfaction for Reproductive and Child Care and Services is at outputs and least at 75%. outcomes to be * High risk pregnancies reduced by 60% by 2010 assessed and * Contraceptive Prevalence Rate (CPR), excluding barrier methods, over 25% monitored by 2010 during phase * HWV/AIDS prevalence under 5% by 2010. implementation * Improved flow of funds and allocation of resources. * Monitoring and evaluation system routinely used as a management tool at all levels in the health system and linked with other sectors. N.B: See also Attachments I and 2 of Annex I of the PAD. Project Appraisal Doocument Project Title: Population and Reproductive Health Country: Guinea Page 5 The project The overall development objective of the project (phase I) is to initiate priority activities and set the building blocks (i.e. legal and regulatory frameworks, managerial and delivery processes) of the phased program in support of the Government of Guinea's efforts to improve (1) awareness of population issues and promotion of safer reproductive health behavior; (2) the quality and utilization of priority reproductive and child health programs; and (3) institutional capacity to manage and coordinate Population and Reproductive Health Programs. In addition to the performance indicators defined in the logical framework, this first phase includes the following activities that will be tested and adjusted as the program expands: (i) Standardized Supportive Supervision of Reproductive Health; (ii) Quality Assurance of Care and Services; (iii) Active Participatory Research at community level that will lead to participation in solidarity funds scheme for Safe Motherhood; and (iv) Monitoring effectiveness of the administrative set-up and ensuring more structured participation of beneficiaries and communities in local decision making for reproductive health matters. B: Strategic Context 1. Sector-related Country Assistance Strategy (CAS) goal supported by the project (see Annex 1): CAS document number: Report No.: 17183 GUI Date of latest CAS discussion: 12/16/1997 CAS objective: "To improve the quality of service delivery for poverty reduction". "Helping improve service delivery is an important cornerstone of our strategic framework, and will be pivotal to the enhancement of Guinea's growth prospects. Access to key public services and effective human resource development would, by maximizing human productivity, help reduce urban and rural poverty". Regarding Population, the CAS states that "Population problems in Guinea are substantial. The Government recognizes the macroeconomic and social implications of population growth and is fully committed to addressing the issue. In addition to the emphasis on girls' education, there is also recognition of the need to enlarge the scope of family planning services and to ensure their integration into the Primary Health Care (PHC) system. The program targets for 2010 are to bring down the rate of population growth to 2 percent and reduce the crude birth rate to 33 live births per thousand inhabitants. The population and reproductive health project will provide an excellent window for addressing gender-related concerns and would finance a population support fund specially targeted at the reproductive health of women and other vulnerable groups". 2. Main sector issues and Government strategy Background information Although Guineans are often moving back and forth from rural to urban areas, three - fourths of the resident population are considered rural dwellers, a third of whom still live in remote underserved areas. Total resident population was 6,505,355 inhabitants in the 1996 Census, with an annual Project Appraisal Doocument Project Title: Population and Reproductive Health Country: Guinea Page 6 population growth rate of 2.8%, one of the highest rates in Sub Saharan Africa. As of 1992, the median age for marriage was 15.8 years, and total fertility rate (TFR) was 6.1 live births per woman between the ages of 15 - 49 (est. from DHS 1992). Guinea is comparatively disadvantaged in the Africa Region: the Infant Mortality Rate (IMR) is around 137 per thousand (103 for Sub Saharan Africa, SSA); the infanto-juvenile mortality rate is estimated at 229 per thousand (157 for SSA in 1995), and is higher in Upper and Forest Guinea. Adult illiteracy was very high until 1990, with 76% of the total population and 85% of the female population being illiterate. Thanks to the combined efforts of Government and donors, notably USAID and the World Bank, female primary school enrollment has tripled during the last six years (37% in 1997). Government strategy Health Sector strategy: In November 1991, after assessing the actions undertaken since 1984 (the year of the National Health Conference), the Government promulgated a new Health Policy Statement (D6claration de Politique Sanitaire). This document clearly stated that the policy objectives are to improve the health status of the whole population by reducing morbidity and mortality through a focus on vulnerable groups, particularly women and children. Another main objective of this policy was to improve the supply, accessibility, quality, and efficiency of health services. Moreover, it was stated that measures should be taken to control the population growth. The latter was reinforced by the adoption of the National Population Policy in May 1992. During the National Forum for the Health Sector held in May 19-21, 1997, the following five priority strategies were adopted for the next program cycle from 1998 to 2010: (1) decentralization of the health system and improvement of health coverage; (2) strengthening of managerial capacities; (3) improvement of funding and financial management for the Health Sector; (3) strengthening of integrated management of diseases and ; (5) improvement of reproductive health programs. The first four priorities are already being addressed by the ongoing Bank-funded project, within the framework of provision and expansion of health and nutrition services. Population and Reproductive Health: Government's commitment to solving population growth has been translated into the following actions: provision of institutional support to Reproductive Health as one of the five priority-strategies of the next program cycle (1998 - 2010); promulgation of an official statement targeting a contraceptive prevalence rate (CPR) of 25 - 32 % by 2010, and, in April 1997 the launch of a program of action aimed at overriding legal barriers to the sale and advertisement of contraceptives. Following the recommendations of the 1994 International Conference for Population and Development (ICPD) in Cairo, the Reproductive Health program in Guinea was redefined to meet the fertility needs of the population at different stages of the life cycle. Therefore it includes four specific programs targeted at specific segments of the population and a common Information-Education-Communication (IEC) program or Behavior Change Communication Program (BCCP). The Reproductive Health policy, program, norms and procedures were also approved by the Government during the National Forum for the Health Sector. Family planning services are only being offered in 139 of the 321 health centers, mostly located in populated and culturally diverse areas. There are plans to install post-partum family planning services in 15 of 33 prefectoral maternities and in two of the eight regional hospitals. The needs of rural areas were recently addressed, with the Upper Guinea model of Community-Based Distribution being upheld since March 1997 as the most cost-effective strategy for rural areas. It is now being expanded within this region as well as in other villages in Forest Guinea. Finally, a Social Marketing program has started supplying condoms and other family health-related products in 3,400 urban and rural sales Project Appraisal Doocument Project Title: Population and Reproductive Health Country: Guinea Page 7 locations. With regards to HIV/AIDS, according to the projections of the "Programme National de Lutte contre le Sida" (PNLS), without reinforcement of the program, HIV adult seroprevalence would increase from 1.5% in May 1996 to 6% in 2000. Local non governmental organizations (NGOs) and their current roles Constituency for Population and Reproductive Health has been efficiently active since 1982, with prominent advocates being grouped under The Guinean Association for Family Welfare ("AGBEF"). Besides its advocacy role for the advancement of the Population and Reproductive Health agenda, the association is providing services in 15 family planning clinics that are all located in urban areas. AGBEF has four decentralized regional coordination bodies and has satisfactorily implemented programs in collaboration with international NGOs such as PSI, Inc., and with the UNFPA Field Office in Guinea. With regard to gender issues, there is still a range of female genital mutilation (FGM) practices, despite their constant adverse and sometimes dramatic consequences on women's health in all regions of Guinea. Fortunately, the issue is gradually making its way to the priority list, thanks to the efforts of indigenous NGOs such as: the NGO of women lobbyists (CPTAFE), the NGO of national researchers on Reproductive Health (CERREGUI) and the national association of women against sexually transmitted diseases and AIDS (ASFEGMASSI). NGOs are currently engaged in building a coalition and setting up action committees. 3. Sector issues to be addressed by the project and strategic choices: Issues addressed by the project Strategic choices 3.1. Population growth and low contraceptive prevalence rate: High population growth: A high population Noticeable improvements in the standard of living growth rate of 2.8% per year, with GDP will not take place unless bold actions are carried standing at 4% and per capita income out to slow down population growth. To do this, increasing only at 1.2%, will offset the the first phase of the program will seek to obtain accomplishments of the poverty reduction involvement at the decision making levels, as well as program. to establish broad-basedpopular awareness and endorsement of reproductive health programs. Consensus building through policy dialogue, involvingfull participation of local NGOs, will be funded. Each of the three phases of the program will address the unmet needs of youth and support interventions to address population momentum and its consequences on social sectors and the labor force. Project Appraisal Doocument Project Title: Population and Reproductive Health Country: Guinea Page 8 Population momentum: Births in larger The sub-programfor youth intends to complement youth cohorts will be much higher than those other donors ' actions in schools and youth centers in older cohorts, leading to the doubling of the and informal gathering places. Prevention and safe population within 20 years and widening the behavior (relating to safe sexual practices) will be gap between economic and population growth promoted through messages for youth groups, rates. Moreover, studies have shown that nationwide, through various media. knowledge of positive and safe health practices and sexually transmitted infections (STIs) is insufficient among adolescents and young adults. Thus, the AIDS fatality rate among young women is likely to increase, and sexually-related morbidity might greatly strain the already meager health resources and further decrease overall economic productivity. Initial high population growth and population Most young Guineans are caught between momentum are further aggravated by use of traditional values and behaviors and the waves of low contraceptives. relatively new modern culture, so there is a crucial need to harmonize diverse influences into a renewed family-life education. University and school-based health centers, youth organizations and youth centers will be strengthened to provide basic family- life education, information and counseling services for reproductive choices, and referral mechanisms for emergency contraception and treatment of sexually transmitted infections (STI) by specialized services. Low overall contraceptive practice: although Within the Reproductive Health framework, and at contraceptive services are offered in a third of the level of Safe Motherhood interventions, family the country's primary care centers and planning is yet to be viewed by most health contraceptives are highly subsidized, the practitioners, medical officers, health managers and contraceptive prevalence rate (CPR) for key decision makers as highly cost-effective for modem methods, including condoms, was reducing infant, child and maternal mortality rates, under 5% in 1992. Service statistics showed while maximizing the effects ofpoverty alleviation that while 62% of pregnant women attend at programs. least one prenatal visit, the number drops by more than half for post-natal visits and the CPR for modem methods is under 5%. Bank- funded baseline data suggest that the majority of providers need skills' upgrade on Family Planning, as well as regular supervision. Except for the AGBEF clinics, the extent of Family planning and service for HIVISTIs will be involvement of the private sector in family expanded to improve physical access by diverse planning delivery, although admittedly still target groups. Services will thus be made available limited, is likely to be underestimated. The in the following locations: health centers, model Project Appraisal Doocument Project Title: Population and Reproductive Health Country: Guinea Page 9 private sector comprises a large informal clinics and clinics for high risk groups; University sector in villages and small cities consisting of and school based health facilities; post-partum an unknown (but probably significant) care in maternities and community based, door-to- number of practitioners of traditional door services; and private pharmacies and vendors medicine. These complement a small formal in the Social Marketing program. sector that employs about 57 medical doctors and dentists, 51 nurses, and 128 pharmacists, all based in urban areas. The program will support supervisory training of facility-basedpractitioners, health promoters and trained/supervised independent distributors. Upon completion of initial courses, and to avoid skill erosion, trained providers will take home minimum equipment and a three to six month start-up kit of contraceptives and essential drugs. Expansion of quality family planning in the private sector will be directed towards health care providers and private pharmacies in the formal private sector, as well as towards trained and supervised independent community-based distributors and vendors of the Social Marketing program. An effort will be made to inform potential users of the advantages of seeking affordable services from trained, licensed and supervised providers, distributors and vendors. Traditional determinants of fertility behavior: The sub-program will support behavior change Despite constant and sometimes dramatic communication activities that will help women to consequences on women's health, a range of safely achieve their reproductive goals, while female genital mutilations are still practiced developing culturally acceptable gender awareness. for traditional and non-religious reasons in all Involvement of NGOs, such as COFEG, will be regions of Guinea. systematically soughtfor the implementation of grassroots programs financed by the Population Support Fund (PSF). Eligible NGOs could be, for instance, women 's groups or cooperatives requesting the introduction of reproductive health information, or services, in their activities, or NGOs that are in the process of building a coalition to drastically reduce harmful traditionalpractices. Examples of activities that can be funded include "reconversion des exciseuses" and "vacances sans excision ". Furthermore, within the extended family, a The booklet "Guide Pratique des Droits de la woman's integration depends on the birth of a Femme" will be made available throughout existing first child. Male children are valued by women 's centers and centersfor legal assistance to Project Appraisal Doocument Project Title: Population and Reproductive Health Country: Guinea Page 10 women because they are the gateway to women. Support will also be provided to advocates earlier access to land attribution, and thus a of women 's rights andfor activities aiming at regular personal source of income, as well as completion and adoption of the Family Code. power in the household. A large number of children can further enhance a woman's The PSF will also finance the creation of prestige in the family and communities. community-based solidarityfunds for the risks Finally, male children are equally valued by related to pregnancy and childbirth. men and women because they will later give the fathers more political clout in the community. 3.2. Insufficient prevention of STI/HIV/AIDS: Contraceptive practice is not always Due to the absence of a cure and the high costs of accompanied by a consistent prevention of the treatment of opportunistic infections caused by transmission of STI/HIV/AIDS. Data from AIDS and its lethal outcome, the program will the National Program of Action against emphasize prevention of STI and HIV infection STI/AIDS (Programme National de Lutte among the large youth cohorts (IO - 24 years old), contre le SIDA, PNLS), the West African through a strong communication program for program of Canadian Cooperation and behavioral change. A behavioral change SIDALERTE - Guinee showed that the communication program will include messages and primary mode of transmission in Guinea is sessions on adequate and consistent use of heterosexual contact. STIs rank 6th among condoms. As decision makers in families and causes of reported morbidity, with gonorrhea communities, men andfathers will be priority ranking 7th in outpatient statistics, targets of the communication program. However, nationwide. Syphilis seroprevalence among women 's NGOs such as ASFEGM4SSI will be screened pregnant women varies from 9.8% involved and supported in Northwestern prefectures to 11.8% in the prefecture of Kindia. But prevention of HIV/AIDS will never be totally effective unless the propagation of the AIDS As for HIV, seroprevalence among sex epidemic has been greatly reduced. The first phase workers was 32% in 1994. In addition, of the program will therefore address, at the regular use of condoms is reported to be primary care level, the needs of groups at highest under 50% in the population at highest risk risk such as sex workers and their clients, internal such as commercial sex workers. HIV is also migrant workers, and long distance truck drivers, reactivating primo-infection of tuberculosis, by supporting the creation and operation of or aggravating tuberculosis symptoms. screening and treatment services of STI/HIV/AIDS Screening of nearly two thousand tuberculosis in areas of exodus and intense circulation. patients found in 1993 an overall HIV Matching funds could be made availablefrom the seroprevalence of 5.5%. Although AIDS PSF to communities that provide support services prevalence is under 2%, the trend is toward a for AIDS patients. noticeable increase, with Guinea already having an epidemic of AIDS. Reported AIDS At the referral level, the program willfinance cases numbered only eight in January 1987, regional STI/HIV screening and counseling services but within less than a decade, the cumulative for persons diagnosed with HIV infection and their number of AIDS cases had reached 3080 entourage. Regional support to tuberculosis (December 1996). patients with AIDS will be assessed during the first period of the project. Project Appraisal Doocument Project Title: Population and Reproductive Health Country: Guinea Page 11 Furthermore, on the other end of the continuum of HIV/AIDS care and services, the program would contribute to the installation of safe blood banks and laboratories in the national andfour regional Jhospitals. 3.3. High rates of infant, child and maternal mortalities: High total fertility rate per woman is Child Survival activities and Early Childhood explained by the fact that women of Development activities will be included in the reproductive age are trying to compensate for program. Support to maternal health services will high infant and child mortality rates. High be funded fertility in turn leads to an increased number of high risk pregnancies and maternal deaths. Malnutrition among women and increased Young children are affected by the health status and childhood illnesses Women are suffering well being of their mothers. Adequate nutrition and from malnutrition and anemia in Guinea. care provided to women during pregnancy, delivery This is so because without an average birth and post-partum will significantly affect the survival spacing of 24 months between the end of the and physical, emotional and mental development of breastfeeding period and the beginning of the children. Accordingly, in addition to behavior next pregnancy, there is not enough time to change communication for safer pregnancies and reach the required energy level to safely births, the program willfund community-based expect another child, resulting in low birth services for maternal nutrition, child survival and weight of newborns. Among under 5 year old early childhood development (e.g. outreach and children, a third of those aged 3 months to 5 growth monitoring community programs; years suffer from chronic malnutrition, 11.5% preparation of local weaningfoods and from acute malnutrition. Malnutrition is immunizations). During its three phases, the reported to be the third cause of death (18%), program will support immunization outreach after combined deaths by measles and acute activities and supervision and training offacility- respiratory infections (30%). To lessen basedproviders on "Integrated Management of mortality from malnutrition-related childhood Childhood Illnesses " (IMCI), including treatment of illnesses, Guinean public facilities are proteino-caloric malnutrition. simultaneously delivering preventive and curative services through the "strategy to decrease missed opportunities". Post operative, post-cesarean infections often In collaboration with rural communities, the occur in prefectoral hospitals of underserved program will build and equip 10 maternity waiting areas, because one operating theater is used shelters. Teams atprefectoral maternities will for all surgical emergencies for the entire receive the means to undertake safe motherhood prefecture, often without allowing the 72 activities, such as distribution of micronutrients for hours of mandatory regular sterilization. pregnant women, identifcation and organization of reliable communication and transportation systems between communities, health centers, emergency obstetrical services, as well as subsequent periodic supervision of trained/skilled birth attendants. Project Appraisal Doocument Project Title: Population and Reproductive Health Country: Guinea Page 12 Health teams in prefectures and health centers will befundedfor training in Emergency Obstetrical competencies and life saving techniques, as well as supportive supervision of maternal health activities and services, from communities up to referral services. Ten prefectoral hospitals of the most underserved areas will be equipped with obstetrical operating rooms, intensive care units and post operative wards. Each referralfacility will have an operational Quality Assurance Committee (QAC). To begin with, support will be provided to existing "Comites d' Hygiene Hospitaliere" to enable them to modify their scope and means to conduct prevention of nosocomial infections and Quality Assurance, or at least Quality Improvement activities. Weaknesses of support services for The project will provide assistance to strengthen reproductive and child health: implementation regional andprefectoral supportfor services. of reformns for decentralized management has been delayed due to insufficient planning and limitation of resources that Government can allocate. Regulatory, administrative and fiscal responsibilities remain at the central level. With budget and resource allocation being centrally managed, delays of six months or more often occur between allocation and Lutilization by regions and prefectures, which undermine the services rendered and result in delays in funding requests for the next fiscal year. Databases of personnel involved in Regional and prefectoral levels will be supported reproductive and child health are not for decentralized management and coordination of maintained at implementation levels of the reproductive and child health programs and health systems, which makes it difficult to improved allocation of resources, in collaboration manage in-service staff training and with bilateral and multilateral donors active at development. regional level. Prefectoral annual workplans, budgets and supervisory training for Reproductive and Child Health will be standardized, nationwide. Elements of Health Management Information System that are directly connected to Reproductive and Child Health will be strengthened by the project. Project Appraisal Doocument Project Title: Population and Reproductive Health Country: Guinea Page 13 Databases of health personnel and auxiliaries will be updated to include evaluation of performances;skills ' assessment and training needs; upgrading of skills will be carried out, in the form of supportive supervisory training, and later through the operations of quality improvement teams on service delivery sites. Physical inventories of equipment and Assistance for other support services at these material are available at central level, but implementation levels will include: operational inventories of the same cannot be (a) repairs or replacement of critical elements of regularly updated at implementation levels. contraceptives, essential drugs and vaccines/cold Logistics for the Enlarged Immunization chain logistics; program (EPI) are operational but most of the (b) improved capacityfor drug supply, storage, equipment and materials need repair or distribution and utilization by setting the replacement; up until now, the logistics managerialframeworkfor proper inventory; system has been almost totally dependent on adequate forecasting and timely procurement; donor support. quality assurance ofproducts and timely delivery and ordering of supplies; and education of consumers andproviders. At the beginning of the first phase, the program will set the regulatory framework and processes for Quality Assurance of contraceptives, essential drugs and vaccines. In addition, the project will renew one-year buffer stocks of contraceptives and generic essential drugs for regions, health centers and distributors in project areas, selected school-relatedfacilities, and model clinics; (c) strengthening of the Quality Assurance of service delivery. The program willprovide support to the public office in charge of: application of norms, procedures and standards setting; quality improvement of delivery; monitoring of client satisfaction; supervision and accreditation of private health care facilities, licensing of categories ofproviders and trained vendors; and enforcement of rules and regulations. The Public Health Code will be made available to all regional and prefectoral health offices. Project Appraisal Doocument Project Title: Population and Reproductive Health Country: Guinea Page 14 C: Project Description Summary 1. Project components (see Annex 2 for a detailed description and Annex 3 for a detailed cost breakdown): Component Category Costs of 1 st phase % of Total (US$M) (1) - initiating - Institutional, physical, awareness of policy, behavioral change population issues; communication promotion of safer 4.50 40 reproductive health behavior (2) - launching - Institutional, physical, improved quality of policy, Quality of Support and access to Services and Care 6.00 48 services in order to increase utilization of priority reproductive and child health programs (3)- setting - Institutional capacity institutional building capacity to better - Project management 1.50 12 manage and coordinate Population and Reproductive Health Programs Total 12.00 100% Project Appraisal Doocument Project Title: Population and Reproductive Health Country: Guinea Page 15 2. Target populations and institutional beneficiaries Target populations: The project (or first phase of the program) is expected to cover approximately 30 % of the total population as follows: Target groups for demand side activities (i. e. advocacy, communication for behavior change): - decision makers from public and private sectors; - community opinion leaders, fathers and male heads of household; and - youth, low income women and communities; Target groups for supply side activities (i.e. quality and access for reproductive health and child health services): - adolescents and young adults (10 - 24 years old) in selected areas = 600,000; - women of reproductive age (15 - 49 years old) in selected areas = 591,360; - children under five years old in selected areas = 290,182; - reproductive health practitioners from public and private sectors in project areas; - unemployed junior physicians and unemployed junior nurses Institutional beneficiaries: Ministry of Planning and Cooperation: The National Commission on Population and Human Resources ("C.N.P.R.H.") and its Executive Secretary Ministry of Health: - Division of Reproductive Health, namely its decentralized programs of family planning, safe motherhood, child health, and Communication for Behavior Change (formnerly IEC); - School Based Health Services (" Service National de Sante Scolaire et Universitaire"); - The National Program of Action against STD/AIDS ("Programme National de Lutte contre le SIDA ") - Division of Logistics Support for the EPI/Primary Health Care/Essential Drugs programs; - 8 Regional Health Inspections; - 33 Prefectoral Health Management Directorates and selected primary care and referral services. Ministry of Youth, Sports and Civic Education: Division of Socio-Educational Activities and its decentralized entities. Ministry of Social Affairs, Promotion of Women 's Status and Childhood Development: * Division of Promotion of Women's Status and its decentralized entities * Division of Early Childhood Development and its decentralized entities Project Appraisal Doocument Project Title: Population and Reproductive Health Country: Guinea Page 16 3. Benefits a. A better understanding of population dynamics and issues by key people, and improved ownership programmes: The message to all target groups is that "investments in reproductive health have multiple payoffs for families, communities and the national economy." Presentation of facts and economic and demographic projections during advocacy sessions are expected to develop stronger and more active constituencies for Population and Family Planning programmes. This in turn will create and maintain the conditions of sustainability and increase national ownership of fertility regulation and prevention of STI/HIV infection programs. Over time, the endorsement of a slower population growth by all decision makers at all levels will lessen, in a cost-effective way, the imbalance between population and economic growth levels. b. Safer behavior among the youth cohorts, reduced health risks for women, increased child survival and development: Within the context of family-life education, safe sexual practices will be promoted among youth cohorts up to 25 years old. The behavioral change communication program will also promote planned parenthood in families through the promotion of delayed first pregnancies, avoidance of births among older women, sufficient birth intervals, and fewer births. Practice of family planning is known to have a positive effect on mothers as well as on infants and young children; when the number of high risk pregnancies ("too young, too late, too often and too many") is reduced, the health status and survival of children under five years old is significantly improved (18% of the total population in Guinea). Furthermore, targeted behavioral change communication programs will stimulate the demand for preventive services such as prevention of STI/HIV infection; family planning; early detection of risks during pregnancy and childbirth, child survival, and early childhood development. These interventions have been proven to be highly cost-effective in improving health status by decreasing the three major mortality rates in Guinea (infant, child and maternal). c. Efficient service delivery: Support to the supply side of reproductive and child health will generate a culture of quality assurance of care and services (QACS) among medical officers and providers. Quality service will emphasize the importance of addressing clients' needs and the necessity to monitor client satisfaction. Improved managerial systems and better support for services will maximize the use of allocated resources. Expansion of coverage of both preventive and curative services will bring services closer to beneficiaries and thereby increase utilization of the same. Improved interpersonal communication during clinical encounters between providers and beneficiaries will generate confidence and trust. d. Effective intrasectoral and intersectoral policy dialogue will result from the utilization of relevant, accurate, reliable and easily accessible data. Such data will reduce uncertainty in decision- making at all levels, especially during the planning, monitoring and evaluation phases. Data will also be made available to both public and private sectors for advocacy on population issues and better management of reproductive health programmes. Finally, a better dissemination of data will result in better circulation of information and greater transparency of program processes. 4. Institutional and implementation arrangements Implementation period: Four years, covering the first phase of the three phase program spanning over a twelve year period. This duration will parallel the Government's long term commitment to population goals, will allow sustainability to develop and facilitate evaluation of outcomes and impact after a reasonable period. Subsequent credits will be extended after achievement of agreed upon performances, in conformity with critical milestones and trigger indicators. Project Appraisal Doocument Project Title: Population and Reproductive Health Country: Guinea Page 17 Executing agency: A Coordination Office in the Ministry of Health ("Bureau de Coordination Population-Sante") -- also acting as a technical arm for the C.N.P.R.H. (National Population and Human Resources Committee), would be the project's executing agency. Given its multisectoral nature, the project would be executed under the coordination and facilitation of a team supervised by a National Coordinator with qualifications in Reproductive Health and Management of Health Services, as well as experience in management of Bank-funded projects. The project staff will consist of three professionals with the required skills in: (a) demography and statistics, to be responsible for the project monitoring and evaluation system, and support to the C.N.P.R.H.; (b) behavior change communications, to coordinate the subset of related activities carried out for various target groups; and (c) community organization and participation, to provide support to the PSF selection committee and collaborating NGOs. The Coordination team will be supported by MS/DIEM for all procurement activities (see Annex 6) and by MS/DAAF for accounting and financial management (see below). Implementation of project activities will fall under the responsibility of relevant line agencies at central, regional and prefectoral levels of the Ministry of Health; Ministry of Youth-Sports and Civic Education; Ministry of Social Affairs-Promotion of Women's Status and Childhood Development, and Ministry of Planning and Cooperation.. Local NGOs will be encouraged and utilized to implement activities for which they meet qualifications and requirements, or for which they have a track record for operational excellence. All arrangements, relationships and responsibilities will be clearly mentioned in the project implementation manual. Project oversight ( policy guidance etc.): - A renewed National Committee for Population and Human Resources ("Commission Nationale pour la Population et les Ressources Humaines" or C.N.P.R.H.) will be the lead institution for advising on and facilitation of policy dialogue and for follow-up of program implementation. - The Ministry of Health will have the oversight of the execution of reproductive and child health programs. Depending on the targeted groups and type of activities, managerial support for services will be planned and monitored by the following central level bodies: Division of Reproductive Health, Primary Health Care/EPI/Essential Generic Drugs program ("PEV/SSP/ME") at Ministry of Health for family planning, safe motherhood and child health activities; Division of Socio-Educational Activities at Ministry of Youth, Sports and Civic Education for behavioral change activities among youth cohorts; National Directorate of Statistics and Division of Population and Human resources at Ministry of Planning and Cooperation for support to the National Commission for Population and Human resources ("C.N.P.R.H") ; Division of Promotion of Women's Status and Division of Childhood at Ministry of Social Affairs, and Promotion of Women's Status and Childhood for Early Childhood Development and Population Support Fund activities. The project components will mostly be implemented by regional and prefectoral entities of Ministries involved. The project will strive to avoid delays with the following trigger/"rain or shine" activities: (a) at the prefectoral level, the annual review of project achievements will take place during the last quarter of each year and prefectoral annual workplans and budgets for the next fiscal year will be submitted every year to the regional directorates, no later than November 30th; (b) at the regional level, the annual review of last year's performances will take place during the first quarter of the current fiscal year. Regional annual work plans and budgets should be submitted every year to the National Coordination Office, no later than February 28th; and (c) the review of performances with IDA staff and other donors will take place every year in May, followed by the planning of project operations for the next fiscal year. Decision-making patterns within concerned agencies and the flow Project Appraisal Doocument Project Title: Population and Reproductive Health Country: Guinea Page 18 of resources for implementation will be reviewed during project preparation, with special attention being paid to accountability requirements. Accounting and financial arrangements: The MS/DAAF, which is handling satisfactorily the financial management of the ongoing IDA- financed project (PSN), will also be responsible, under the authority of the head of the BCPS, for the project's administrative and financial management and reporting, including making arrangements for annual certification of project accounts, and following charts of accounts, systems and procedures for conformity with IDA requirements. The MS/DAAF will be provided with the necessary resources to strengthen its operational capacity. All project-related expenditures and financing will be done in accordance with International Accounting Standards. The financial management information system has been assessed and found satisfactory since it allows the monitoring of expenditures per category, per sector (or Ministry), per set of activities within each sector, and for each level of implementation (central, regional, prefectoral). A special account for the IDA credit will be opened and maintained with a commercial bank acceptable to IDA. An independent auditor, acceptable to IDA, will audit the use of all IDA funds applied in financing the project, including the special account and statement of expenditures. Monitoring & Evaluation Activities: Monitoring will be conducted twice a year, around May and November, through interviews of key people, review of documents; review of quarterly reports at the prefectoral level, and annual audits at regional levels. Field visits will also be carried out at randomly sampled locations. Evaluation will be based on the indicators in Annex 1, as well as on the matrix of actions and monitoring indicators included in the project implementation manual. Indicators: Inputs: (a)Training in Advocacy, Communications for behavior change and production of targeted messages through various media; (b) standardized supportive supervision and refresher courses for practitioners; (c) organization of QACS in regions and prefectures; and (c) investments for equipment, essential drugs, consumable and civil works. Outputs: reduced number of high risk pregnancies, increased number of deliveries assisted by trained birth attendants, a reduced fatality rate among emergency obstetrical cases, percentage of family planning services provided by trained providers, increased number of continuing users of contraceptives; increased number of partners referred by STI patients; increase of couple - year protection (CYP) per method and per trained provider; percentage of under five year old children treated by providers trained in Integrated Management of Childhood Illnesses (IMCI); and percentage of communities providing Early Childhood Development (ECD) services. Evaluation of the project: The mid-term evaluation will take place in November 2000, with the following activities: review of documents; evaluation of execution modalities and technical assistance; evaluation of capacity building at each level and field visits of random sample of health facilities and community-based activities. Interviews will also be conducted with staff of local NGOs and focus groups with members of targeted groups. An incremental approach to execution is foreseen. At the central level, there will be an annual review of progress towards project objectives and needed corrective actions will be taken accordingly. The project's critical milestones, triggers Project Appraisal Doocument Project Title: Population and Reproductive Health Country: Guinea Page 19 and performance indicators cited in the project design summary (Annex 1) will be the common reference for monitoring and evaluation. They will be updated during the annual review of key performance indicators and operational planning. Satisfactory progress on these indicators will be the preliminary for appraisal of the subsequent phase. Outcomes (or Program Impact, by 2010): improved standards of living; increase of GDP per capita and increased income levels of vulnerable groups; reduction of total fertility rate (TFR) per woman; increased contraceptive prevalence rate (CPR) per type of method; reduction of infant mortality rate (IMR) and reduction of maternal mortality rate (MMR). D: Project Rationale 1. Project alternatives considered and reasons for rejection: 1.1. Strengthening only the Family Planning and STD/HIV/AIDS services: This will mostly address the supply side of services and, without behavior change to channel latent demand, might lead to underutilization of services. Besides, advocacy for awareness of population issues was just introduced last year, so only a few number of key decision makers and opinion leaders are informed on, or have sufficient knowledge of relationships between excessive population growth, slower economic growth, unmet needs of youth population, and lack of equity towards rural women and their children. 1.2. A project with a stronger support to the demand side: This is needed and should be simultaneously implemented with providing support to the supply side. A recent study commissioned by the Bank identified problems on the supply side relating to seriously sub-standard reproductive health services (including family planning), and inadequate funding for supervision at all three levels of the health system. Without strengthening the managerial sub - component and the supply side in general, the demand side will expand faster than the capacity to deliver customized quality reproductive health services nationwide. This in turn would lead to clients' disappointment with family planning services, discontinuation of use, and, ultimately, failure to achieve related outputs and outcomes and progress toward the development objectives. 1.3. A Maternal and Child Health and Family Planning (MCH/FP) Project: This would not be consistent with the endorsement of Cairo ICPD recommendations by the client country and the Bank, and would exclude the youth cohorts and perpetuate the population momentum. Youth segments of population still have important unmet needs for reproductive health and family life education, and attempts to meet such needs are currently being made by LJNFPA and French Cooperation. Under its current program cycle, UJNFPA will support the extension of school-based information on population and five youth centers for the informal sector. The French Cooperation is planning to extend its support to four regional centers, but only after the completion of a pilot test in two youth centers located in Conakry. These noteworthy efforts are, however, far from responding to all the needs of two millions adolescents and young adults (10 - 24 years old). A MCH/FP project would also exclude specific groups at highest risk for STI/AIDS that are currently trying to seek services in the often unsafe informal private sector. Project Appraisal Doocument Project Title: Population and Reproductive Health Country: Guinea Page 20 1 .4. Separate sectoral projects that are executed respectively by the ministries involved: This alternative is usually preferred. However, it will not actively seek to maintain or increase intersectoral linkages that are necessary to reach the priority target groups. Separate projects dealing with reproductive health issues will create difficulties of coordination and will also disregard the need for a carefully sequenced coordination of a project that has at stake individual, societal as well as mnacro economic interests. 2. Major related projects financed by the Bank and/or other development agencies (completed, ongoing andplanned): 2.1. Bank-financed: Completed: Development of Health Services Project: by project closing in June 1996, Middle Guinea was benefiting from improved primary health care and referral services, norms and standards for running health care activities, a functioning cost recovery scheme, and, at the community level, a mechanism to involve the beneficiaries in the management of health facilities. Moreover, the performance of the Ministry and of the technical programs supported by the project was substantially improved. Overall, the project outcomes were satisfactory. Ongoing: Health and Nutrition Project: this project focuses on development of health services in Middle and Lower Guinea and strengthening of priority programs. The project is currently entering its second of three planned phases. New performances indicators are to be identified as part of the retrofitting exercise. Ongoing: Equity and School Improvement Project: this project aims to expand the gross primary school enrollment rate, improve student teaching and learning, and strengthen education system management. Each project component has been designed to address constraints to education of girls. The project has tripled primary school enrollment of girls during the last six years. 2.2. Other development agencies: UNFPA- KfW: A new program cycle of five years was started in March 1997. The total level of funding is $ 5.5 million for a nationwide program that will increase the availability of services and demand for Reproductive Health services. KfW is cofinancing $ 2.5 million for the procurement of contraceptives. KfW - AGBEF - OSFAM / PSI, Inc. : This is a planned project; level of funding will be under $1 1.0 millions for technical assistance and local costs of Social Marketing and Community Based Distribution of Services for Reproductive Health. UNICEF: A nationwide program is planned under the new program cycle for the period of 1997 - 2001. The level of funding is $ 5.1 million and the main priority will be to strengthen activities that benefit directly or indirectly children under five years old. Project Appraisal Doocument Project Title: Population and Reproductive Health Country: Guinea Page 21 USAID: A request for a proposal (RFP) was issued on June 1997 for a Family Planning and Health Activity (FP/H) and STI/AIDS Prevention. Level of effort will be $ 21.0 million for four years, to finance technical assistance and activities to be implemented in Upper and Forest Guinea (a total of 12 prefectures). EEC: is planning to participate in the reorganization of the "Pharmacie Centrale de Guinee ". 3. Lessons leamed and reflected in the project design: The project's rather complex design, compounded by the sector's poor administrative performance and structural flaws, has led to delays in implementation. It would have been more appropriate, considering the situation that prevailed in Guinea in the 1980s, to begin by addressing the sector in its entirety through adjustment or sector-wide investment operations (with strong capacity-building components). Under the ongoing bank-funded Health and Nutrition Project, the implementation capacity of the health sector is being greatly developed. Institutional capacity has greatly improved and project execution is proceeding as scheduled While the overall outcome of cost recovery is favorable, the question of whether cost recovery affects the accessibility of the poor to health services ought to be further addressed. This matter should receive proper attention in all Bank-funded projects in low-income countries. User fees for reproductive health services will be assessed by this project and will be set at levels low enough not to deter the use of quality services, while remaining competitive with vendor fees in the informal sector. Low utilization rates are still common features in most in-patient and out-patient health facilities. This indicates that specific quality control measures and surveys should be carried out regularly to further improve utilization rates and health service outcomes. A behavior change communication program will be designedfor segments of population to stimulate demand. Interviews of community leaders and client satisfaction surveys will be scheduled to monitor the quality of and satisfaction with services. On the supply side, as Guinea has recently adopted norms and procedures of Reproductive Health, they will play important role in the continuing education of reproductive health providers and in providing Quality Assurance programs at the regional level. The weak family planning outcomes show that strong, high-level political support and a convincing effort to sensitize the target groups are needed from the start of the project, along with proper primary health services, to boost the demand for modern contraception. The proposed project will promote intersectoral policy dialogue and an awareness of population issues through an advocacy program aimed at decision makers. The project's behavior change program will address each step of behavior change: facts and accurate information will be provided through small and various mass media, whereas personalized information on family planning will be provided through home visits and counseling sessions for individuals, couples or families. Providers will be trained in inter- personal communication techniques and contraceptive technology, and in the syndromic approach of STIs and the prevention of transmission of HI V in health facilities. The project's gender activities were first started at the central level, where countless delays were encountered. Community based activities, on the other hand, gained a quick momentum and were well accepted by beneficiaries. This supports the idea of developing - in parallel and from the beginning, community-based activities, together with more general policy consensus processes. Project Appraisal Doocument Project Title: Population and Reproductive Health Country: Guinea Page 22 Grants to support women 's groups will be awarded. Demographics by gender will be published and gender awareness will be further assessed among opinion leaders and decision makers, as well as among primary beneficiaries. A specific gender policy will be an integral part of the outputs of the project. From other development agencies: While parallel contraceptive logistics were useful to avoid or correct shortages, the Government was left without a managerial system able to take into account the delays inherent to international procurement of technical services and contraceptives. Contraceptive logistics under the PEV/SSP/ME system were assessed during the preparation phase, and the project has started to provide technical assistance to strengthen regional and prefectoral support for services. The prefecture of Mamou will be specially supported to serve as a proximity warehouse and as a training center for internships in management of essential drugs and contraceptives, and a practicum site for information system, quality assurance, and supportive supervision. 4. Indications of borrower commitment and ownership: * The GOG made official population policy statements and approved the Guinea population policy in May 1992. Recommendations of the International Conference on Population and Development (ICPD, Cairo 1994) were later included in the policy document, and MCH / FP policy and programs were revised accordingly. As for implementation of the Population program, it needs to be reinvigorated, especially the advocacy component that was just started in 1996. * The GOG confirmed its commitment to the population policy by sending a letter to IDA in September 1996 that outlined its population policy framework and requested support for a population and reproductive health project In particular, the letter of intention stated the Government's goal to increase the contraceptive prevalence rate from less than 5 % in 1992 to 25 % by 2010. * Project identification and pre-appraisal missions took place as scheduled and benefited from a wide participation of civil society and Government leadership. A national project preparation coordinator was appointed, and a technical preparation team and a preparation advisory committee were formed in February 1997. * During the National Forum for the Health Sector (1998 - 2010) held in Conakry in May 1997, Reproductive Health Policy, Program, Norns and Procedures were officially adopted by the Government. 5. Value added of Bank support in this project: The Bank is providing substantial support to the Government of the Republic of Guinea to help execute one of its five priorities in the Health Sector, for the period 1998 - 2010. This project will enable the Government to execute an important part of its population program -- relating to the youth population and gender -- with high visibility and broad popular support. The Population and Health Coordination Office (BCPS) will execute its coordination mandate through the "Comite Inter-minist riel". This high level coordination unit will increase the complementarity and synergy of funded programs within the sectors involved as well as with the Labor, Environmental and Project Appraisal Doocument Project Title: Population and Reproductive Health Country: Guinea Page 23 Education sectors. In addition, the project will give the Government enough resources to effectively take the lead in the execution of population and reproductive health programs. For instance,. the coordination of the execution of Reproductive Health by the Government will maximize the use of resources and will improve the quality and transparency of program processes. E: Summary Project Analysis (Detailed assessments are in the project file, see Annex 8) 1. Economic [] Cost-Benefit Analysis : NPV= N.A. [X] Cost Effectiveness [] Other Analysis: [Specify] Economic & Fiscal Assessment (see Annex 4): The economic rationale for public intervention is firmly established not only on the grounds of equity and poverty alleviation, but also on the basis of numerous externalities and the "public good" nature of key project activities. The fiscal impact is small and not expected to impose any budgetary burden. First, budgetary counterpart funds needed are estimated to amount to FGN 4.5 billion (0.8% of public investment) over the next five years. Second, annual recurrent expenditures arising from project implementation are projected to average GF 0.5 billion (0.2% of recurrent budget). Though Guinea has initiated cost recovery at almost all levels of the health system, a more aggressive action in that regard is perhaps unnecessary before a viable program to protect indigent patients is in place. Moreover, such an action is likely to put significant stress on the poor and dampen low income household demand for health care services. Cost-effectiveness Assessment (see Annex 4): Numerous studies and analyses have demonstrated that the major causes of premature death in Guinea (communicable, maternal, and prenatal diseases) are subject to highly cost-effective interventions. The 1993 WDR (Investing in Health) defined a cost-effective intervention as one where the cost per DALY (Disability-Adjusted Life Years) saved is below US$250; interventions with cost per DALY gained below US$100 are classified as highly cost-effective. Analysis of the cost effectiveness of the interventions financed by the proposed project falls into two broad categories. First, the concept of the US$ cost per DALY saved is used to compare the cost effectiveness of overall interventions, such as antenatal care and immunization, with other interventions in the health sector; and second, the notions of Couple Years of Protection (CYP) and number of births averted are used to analyze the cost effectiveness of alternative forms of service delivery for a number of reproductive health interventions. Finally, the set of interventions supported by the project are compafed with recommendations from cross-country studies such as the 1993 WDR and "Better Health for Africa, 1994". Following a standard practice, project interventions have been grouped into 5 categories, as shown in Appendix 1 of Annex 4. The last category is of particular importance since it gives the cost effectiveness indicator for each population activity, reproductive health intervention and institutional support thereof. The rating range of categories goes from high (H) to low (L) cost effectiveness (CE). Project Appraisal Doocument Project Title: Population and Reproductive Health Country: Guinea Page 24 2. Financial Assessment (see Annex 5): The provisional project costs are estimated at US$ 12.0 million, out of which US$ 11.3 million will be financed by IDA, and the remainder (an equivalent of 6 % of project costs) will be financed by the Government. Over the next 4 years of project implementation, cumulative investment costs will amount to US$9.5 million while recurrent costs stand at only US$2.5 million. These represent a very small fraction of both public investment and public recurrent budgets (see economic analysis). Community participation, coupled with cost recovery for selected hospital services will provide a viable short-terrn solution while a more aggressive expenditure reallocation policy can be Implemented. Financial sustainability will be sought from the widespread community support for the absolute poor. In addition, there is a significant development of various traditional risk pooling mechanisms in the community, which augurs well for the financially sustainable set of population and reproductive health activities financed by the project. 3. Technical Assessment: Technical aspects of the three phased Population and Reproductive Health Program have been assessed by the Bank, with assistance from UNFPA, WHO, UNICEF and USAID. The aim is to render effective the implementation of programs derived from sound population and reproductive health policies. The proposed project will support expansion and strengthening of affordable (subsidized) cost effective interventions on both demand and supply sides of service delivery. The three phased program is also strengthening related critical administrative and support services: coordination of implementation for various target groups; joint annual review of project perfornances; improved support for children's immunization program, contraceptives and essential drugs; and standardized supportive supervision and training of personnel. Primary beneficiaries are vulnerable groups, including the youth cohorts whose needs have yet to be addressed. The proposed program appropriately focuses on improving awareness of reproductive health issues among key decision makers; and on reaching out to targeted groups, families and individuals through various media, without neglecting counseling activities (this is the last and critical customized step towards the practice of safer behavior). Collaboration with community-based providers and independent licensed distributors will provide opportunities to expand supervised services and establish quality assurance in the private sector. Upgrading the skills of practitioners assigned in public facilities, along with the establishment of better working conditions and environment, will have multiple advantages. Some of the foreseen advantages are: setting the requisites for improvements of service rendered; restoring the morale and motivation of providers; and renewing the confidence of clients in public service delivery. Although the program is designed on a national scale for both urban and rural areas of Guinea, its first phase would, however, target geographical areas or groups where baseline data suggest either potential expansion of health hazard, or readiness for utilization of services. Such is the case of groups at highest risk, densely populated rural and urban areas, culturally diverse neighborhoods, and urban areas where members of targeted groups are more aware of the financial costs of having and raising children and would seek the means to postpone pregnancies until they are ready for responsible parenthood. Project Appraisal Doocument Project Title: Population and Reproductive Health Country: Guinea Page 25 4. Institutional Assessment: a. Executing agencies: Lack of resources, reduced resources, or delayed allocation of scarce resources were identified as main impediments faced by Ministries in the execution of programs through their respective line agencies. Otherwise, institutions to be involved in this program have demonstrated a relative capacity to reduce women's health risks through prenatal care, and contribute to the reduction of infant mortality. ,Capacity for monitoring, supervision and Quality Assurance of Reproductive Health, especially family planning, needs to be enhanced at early stages of the first phase, because data collected through these activities would be instrumental in refining national annual operational plans and subsequent coordination of funds by the Government. b. Project management: Through the decentralized services of the Ministry of Health, and decentralized committees of the C.N.P.R.H., the Population-Health Coordination Office (PHCO) will ensure vertical and horizontal coordination of activities that will be carried out by executing line agencies of ministries involved. As the "DIEM" at the Ministry of Health has experience in implementing procurement in accordance with Bank guidelines, this directorate will oversee all procurement-related actions for the three phases of the program. The PHCO will be staffed by a team of experienced specialists recruited for positions that have specific job descriptions. Its personnel would be in place to provide the necessary support in strengthening and assisting in the coordination of funded activities. They would not have to perform tasks other than the ones related to the program. 5. Social Assessment: * In view of the extent of the HIV epidemic. in neighboring countries and intense migration movements of Guineans, awareness of STI/AV infection needs to be improved and reinforced. While fertility patterns and regulation in West Africa are still strongly influenced by gender biases, a gender agenda is fairly new in Guinea. To balance population growth with poverty alleviation programs and to decrease sexually-related epidemics, the gender situation would need to be carefully and objectively assessed. As a first step, data from the DHS 1992 and from the 1996 General Census would need to be analyzed with a special attention' on gender biases. Gender issues would then be among the first topics of an intersectoral policy dialogue. * Female genital mutilation is widely practiced for traditional and non-religious reasons. In an attempt to reduce suffering and infections, some medical staff have started to perform female genital mutilation for younger age groups in urban areas. Such providers therefore have vested interests in this cultural practice. However, the coalition of indigenous NGOs and political action committee (the "CPTAFE") have publicly expressed their intent to gradually limit the harnful practice in every possible way. Guinean and West African authorities on Reproductive Health would need to be encouraged to take a stand on the issue. * Low income groups of rural and urban communities are seeking the services of unlicensed vendors and providers because the costs of services offered in public facilities are now beyond their means. Population Support Funds will assist NGOs involved in grassroots programs that are directly related to reproductive health activities. Project Appraisal Doocument Project Title: Population and Reproductive Health Country: Guinea Page 26 6. Environmental Assessment: Environmental A [] B [] C [x] Category This project would be a category C project, without any direct negative impact on the environment. The project is expected to have important long-term positive environmental effects due to the anticipated reduced fertility resulting from reproductive health services targeted at the youth population, and at older age groups in their fertile years. 7. Participatory Approach: Consensus building and a thorough consultation of primary beneficiaries characterize the approach to project identification and preparation. Such a participatory approach has so far successfully ensured that the proposed project reflects most of the concerns of partners and that it is understood as a priority by all involved. Regarding project identification, national experts and civil service managers have reviewed the problems, identified the project's objectives and components and outlined the project's logical framework. Regarding project preparation, AGBEF and the national technical preparation team has facilitated 21 consultative workshops for representatives of primary beneficiaries, civil service managers, and opinion leaders, and a total of approximately 600 persons made recommendations on this population and reproductive health project. Identification/ Implementation Operation ___________ 1 Preparation Beneficiaries/ Primary and secondary "Communautes rurales et urbaines Identification of community beneficiaries decentralisees" poorest and most groups vulnerable groups Intermediary COFEG (is) Coordination bodies: COFEG, Forum Systematic NGOs AGBEF (col) des ONG (col) and exploration of SIDALERTE-Guinee AGBEF (col) possibilities to ..T)r A rr (,1 collaborate with Fraternite ilvieci,avlztW1 ASFEGMASSI (col) SIDALERTE -Guinee(col) Academic Department of School and University based Health Field visits, institutions Sociology, University of Services practicum Guinea (is) internships at project sites Local Regional consultative "Governorat" (col) oversight on government workshops on decentralized implementation of Population and public services Reproductive Health issues Other donors UNFPA (is) Coordination of funding at central Coordination of UNICEF (is) level; implementation WHO (is) technical coordination committees of EEC (is) GTZ (is), regions and prefectures USAID (is) _ IDA (is) Project Appraisal Doocument Project Title: Population and Reproductive Health Country: Guinea Page 27 F: Sustainability and Risks 1. Sustainability a) building technical sustainability of the national reproductive health program in Guinea is the main concern and thrust of the project. The sustainability will be ensured through regional health offices, in the forn of decentralized staff training and development. Initial in-service training on reproductive and child health will be reinforced through regular standardized supportive supervisory training and the practice of quality improvement on the premises of service delivery. Medical officers and providers will be kept abreast of new developments in reproductive and child health during the scheduled meetings of technical committees. b) institutional sustainability: the project (first phase of the program) is prepared to provide the necessary means to facilitate activities and operations of the permanent secretary of C.N.P.R.H., of regional health offices and to ensure the timely completion of recurrent administrative tasks at decentralized levels of the health system. Further institutional sustainability will be promoted by the benefits derived from common managerial arrangements at regional level, including the effective coordination of resources and activities. This will be facilitated by the triggers described in the attachment of Annex 1. c) during this first phase of the program, and given the externalities and the public good nature of the project, condoms and drugs to treat STIs, as well as contraceptives will be subsidized by IDA and other donors active in Reproductive Health in Guinea. Moreover, financial sustainability has already been addressed on a national scale in Guinea. At the service delivery level, under the Bamako Initiative model, more than two thirds of health centers have adopted cost recovery schemes whereby fees cover a visit and provision of prescribed drugs for either an ailment or an episode of a chronic condition or a risk prevention. More than half (53%) of hospitals in Guinea have a cost recovery rate of non wage expenditures of 50% or more (DNES, 1995). Nevertheless, operations research will be conducted to test and adapt funding mechanisms for critical activities such as supportive supervision of providers. Project Appraisal Doocument Project Title: Population and Reproductive Health Country: Guinea Page 28 2. Critical Risks Risk Risk Risk Minimization Measure R'ating Harmful traditional practices and S Regular follow-up of support by authoritative activism of fundamentalist information sources, and lobbyists that will be trained minorities. on efficient communication and advocacy for population momentum and gender approach. NGOs, namely Guinean Women in Legal Professions and CPTAFE, will be involved in the project's activities to fight female genital mutilations. Grants are awarded to planned activities such as "reconversion of exciseuses" and "vacances sans excision". Weak capacity of C.N.P.R.H. to Managerial capacity of the CN.P.R.H.'s Executive execute its mandate of Secretary will be strengthened by the Project coordinating population Population and Health Coordination Office, acting as programs. its technical arm for population and RH policy dialogue. Weakness of institutions in M Improvement of common managerial processes for managing and coordinating RCH programs, through a differentiated and Reproductive and Child Health sequential implementation (confer to related sub- programs. components described in Annex 2). Actual costs of family planning S Subsidization of costs of reproductive health services, could be a deterrent to including family planning and child health, will be utilization. Youth and persons at resumed by IDA and other donors. highest risk of STIs and HIV cannot access needed Special referral services for youth and STI/HIVclinics reproductive health services. for - persons at highest risks will also be made accessible and affordable. Legal barriers are not effectively M Follow-up of April 1998' s Parliamentary sessions, lifted before project follow-up on subsequent Government Action Plan. effectiveness. Overall project risk rating 'Risk Risk minimization measures Failure to significantly reduce M Obtain continuing support from the prominent hannful traditional practices and members of the C.N.P.R.H. Promote broad public to outweigh fundamentalist information and broad-based support: involvement of activism. the communities and parliamentarians, wide dissemination of project's achievements and results, popular contests on production of audio visual materials and regular roundtable on population and reproductive health issues. Risk Rating: H (High Risk), S (Substantial Risk), M (Modest Risk), N (Negligible or Low Risk) Project Appraisal Doocument Project Title: Population and Reproductive Health Country: Guinea Page 29 3. Possible Controversial Aspects: - Contraceptive services for sexually active adolescents and unmarried girls: The provision, at an early age, of accurate information on body transformations and functions might raise resistance from older, often more conservative, generations. The focus will be primarily on self- identified sexually-active girls and boys, and the aim will be to ensure orientation and referrals for clinical contraceptive and HIV/AIDS prevention services. However, trained youth educators and peers counselors will provide to youth cohorts information on safer behavior and counseling on positive health practices such as consistent use of condoms and other non medical barrier methods. - Non reversible female surgical contraception (tubal ligation): For health reasons, this is generally accepted by both clients and providers of family planning, whereas, male surgical contraception (vasectomy) is generally rejected by the same groups , even though it grants the control of fertility of the couple under the responsibility of men. Furthermore, surgical contraception by choice, rather than to prevent severe complications of existing conditions, is not well perceived by health practitioners. It is therefore essential to train all providers to first respond to the choice of family planning clients with unbiased counseling, by -explaining the advantages and inconvenience of any method. If a choice for voluntary surgical method is confirmed after counseling at primary and referral levels, the signing of informed consent clients will document the choice of a surgical method, and will later protect providers from eventual complaints. - Family Planning, female genital mutilation and other sexually related information provided to general public at prime time: It should be provided to the general public at prime time through mass media. Steps for better acceptability would be: to include the issue into the audience research that precedes the planning of the behavior change sub-programs; to preserve the accuracy of information and messages while using culturally appropriate terms; to obtain support at the highest level; and to ensure regular monitoring through focus group discussion with members of targeted groups, through discussion articles in rural radios and newspapers, and through round tables which focus on the issue on the radio and on television. G: Main Loan Conditions As conditions of Negotiations, the Government transmitted to IDA the following documents: (1) A signed Letter of Development Strategy stating (i) the objectives of the phased program; (ii) the main thrusts of the Population and Reproductive Health project and strategy and (iii) a matrix of monitoring indicators and trigger indicators for the program; (2) A ministerial "Arr8te" on the Population and Health Coordination Office that defines its mandate, roles and functions, its position in the organizational chart and the list and qualifications of key staff; (3) The Project Implementation Manual (including an implementation plan and the model of the bidding document to be used for national competitive bidding for goods and civil works); (4) The procurement plan for IDA-financed activities for 1999-2001. Project Appraisal Doocument Project Title: Population and Reproductive Health Country: Guinea Page 30 As conditions of Board presentation, the Government transmitted to IDA documents which ensured that: (1) The key staff of the Population and Health Coordination Office, as well as the additional staff for DIEM and DAAF are selected according to procedures acceptable to the Bank; (2) The project accounting system is in place and operates according to standards acceptable to the Bank; (3) Members of the PSF selection committee are nominated and the implementation manual of the ;PSF is approved. As conditions to credit effectiveness (1) Counterpart funds covering the first year of the project that is equivalent to eighty thousand U.S. dollars (US$ 80,000) is deposited in the account set up for this purpose; (2) An independent auditor is recruited. Other conditions during project implementation (1) Before December 31, 1999, civil servants with qualifications acceptable to IDA will be assigned to the Permanent secretary of the C.N.P.R.H.; (2) Before December 31, 1999, members of technical committees of QACS of Reproductive and Child Health will be nominated at regional and prefectoral levels; (3) Before December 31, 1999, the exhaustive assessment of service providers' competencies, skills and training needs pertaining to Reproductive and Child Health will be completed and entered in a functional database; (4) Before June, 2000, the regional refresher training on Reproductive Health will be updated and transmitted to the Division of Reproductive Health for eacg health region; (5) Before June 30, 2000, a workplan will be prepared, for each of the four natural region, stemming from the following objectives (i) inform women and girls on the health effects of female genital mutilations, their impact on maternal morbidity and mortality, and (ii) define the conditions of enforcement of the law prohibiting female genital mutilation, and eventually present necessary amendments; (6) Before June 30, 2001, a comprehensive plan to solve current problems of the pharmaceutical sub- sector will be finalized. The plan will address the pricing policy, particularly the subsidizing of modern contraceptives so price will not be a deterrent to consistent utilization. Project Appraisal Doocument Project Title: Population and Reproductive Health Country: Guinea Page 31 H: Readiness for Implementation [ x ] The engineering design documents for the first year's activities are complete and ready for the start of project implementation. [ x ] The procurement documents for the first year's activities are complete and ready for the start of project implementation. [ x ] The Project Implementation Plan has been appraised and found to be realistic and of satisfactory quality. 1: Compliance with Bank Policies [x] This project complies with all applicable Bank policies. Task Team Leader Slaheddine Ben-Halima Sector Manager :/_ __ _2_*__ N,cholas R. Bumett Country Manager Nlamadou Dia Project Appraisal Report Project Title: Population and Reproductive Health Country: Guinea Annex 1: Page I of 15 PROGRAM SUMMARY Narrative Summary Key Performance Monitoring and Critical Indicatorsl Supervision Assumptions _ and Risks Sector-related CAS Objective Poverty reduction -Growth rate of GDP per -(CAS Objective capita: 1996 = 1.2% to Bank Mission) -Impact (2010) = > 5% -Openness of the -Improved health status economy reports Program Development End-of-Program Monitoring Critical Objectives Indicators (by 2010) and supervision assumptions (i) Slower population growth. -Population growth rate: Data sources: Annual average 1997 = 2.8 % monitoring and of GDP growth -Impact (by 2010) = 2 % supervision reports; will go from 4.5% -Total Fertility Rate (TFR) reports on annual in 1996 to 5.8%, 1992 = 5.7; review of between 1997 to -Impact (by 2010) - 4.2 performnances. 2010. - Infant Mortality Rate 1992 = 136,3 %0 Impact (by 2010) = under 100 %0 (ii) Improved reproductive - Maternal Mortality Rate: M & S Activities: and child health services. 1994 = 666; by 2010 = 350 regular reporting to per 100 000 live births Government decision makers and Bank officers; field _______________________________ _ ___ visits Program Outcomes Key performance Means of Assumptions Indicators verification (i) Behavior change that - Reduced number of high -Service statistics; Trained reduce infant, child and risk pregnancies -Intercept interviews; advocates and maternal mortalities - Contraceptive Prevalence -Focus groups; communicators Rate (CPR), condoms and -Public expenditure are active spermicides not included by review 2010= over 25% (ii) Increased utilization of -HIV/AIDS prevalence -Community surveys Comrm-unity priority quality. services stabilized under 5% by -Censuses and DHS involvement 2010 -CYP per modern method per trained provider -Improved flow of funds f and allocation of resources Baseline and targeted values should be shown, with the latter divided into values expected at mid-term, end of project and full impact Project Appraisal Report Project Title: Population and Reproductive Health Country: Guinea Annex 1: Page 2 of 15 (iii) Increased management Regular capabilities monitoring of beneficiaries' reactions. Program Inputs: Costs per Sub-component Means of I Critical US $ M verification assumptions Phase I (Oct. 99 - Dec. 02) 12.0 (see project design Availability of Launching of fundamentals below) essential drugs and initiation of top priority and activities contraceptives Phase II (Jan 03 - Dec. 06) Enduring Strengthening and expanding 16.0 community involvement in Safe Motherhood, Child Health and _____ ____ ____ ____ ____ _______Developm ent Phase III (Jan 07 - Dec. 10) 16.0 Ensuring continuity and sustainability Project Appraisal Document Project title: Population and Reproductive Health Country: Guinea Annex 1: Page 3 of 15 Project Design Summary Project End-of Phase I Monitoring and Supervision Critical Development Indicators Assumptions and Objectives (Phase I) Risks Development Objectives to CAS Objective (1) Awareness of (1) Percent of women in (1) Intercept interviews; (1) - Fundamentalist population issues union who are able to quote Focus groups of members of activism, and safer behavior at least one modem family targeted groups; Community particularly against by at least 50% of planning method: surveys on random samples reproductive choice targeted groups of targeted groups. and modem family 1992 = 27,2%; 1997 = 35% planning, will be 2001 = 45%; 2003 = more mitigated. than 50% (2) Quality, access (2) - a. Reduction of Infant (2) - a. Censuses and DHS and expanded mortality rate (IMR) coverage (towards 1992 =136.3; 2001 = 110; utilization) of 2003 = 100 per 1000 priority reproductive and child health services (2) - b. Reduction of high (2) - b. Service statistics of (2) - b,c,d risk births ( under 18 yrs primary and referral facilities Availability of old, over 34 yrs old; birth and DHS affordable interval under 36 months; reproductive 4th birth and higher rank: services for adolescents and 1992=61%; 1997=55% young adults (10 - 2001 = 40%; 2003 = 30% 24 years old), for persons at highest risk of STI/HIV. (2) - c. Increase of (2) - c. Service statistics of Contraceptive Prevalence primary care facilities and Rate (CPR), excluding Social Marketing sales; barrier methods 1997= 5%; Community-based Information Systems; DHS 2001 = 8 %; 2003 = 10 % Project Appraisal Document Project title: Population and Reproductive Health Country: Guinea Annex 1: Page 4 of 15 (2) - d. Stabilized (2) - d. National and regional HIV/AIDS prevalence HIV screening laboratories; among adults (>1 Syrs old): service statistics of model 1994 = 53.7; 1997 = 100; clinics and hospitals 2001 = 150; 2003 = 200 per 10,000 adults (3) improvement of (3) - a. Timely submission (3) - a. Documents of (3) C.N.P.R.H. institutional capacity of annual operation plans prefectoral annual operation will have the to manage and by all prefectures plans; interviews of staff managerial coordinate capacity to Population and (3) - b. Improved flow of (3) - b. Reports of annual coordinate regular Reproductive Health funds and allocation of coordination meetings; policy dialogue at Programs. resources, according to Implementation reports of central level. The decisions made at annual sectors involved; interviews Population and coordination meetings. of staff health Coordination Office will facilitate intersectoral collaboration at implementation level. End-of Phase I Indicators of results Means of verification Critical Results/Outputs assumptions 1.1.Increased 1.1. Percent of young 1.1. Intercept interviews; (Outputs to proportions of adults (15-24 years old) focus groups of members of objectives) targeted groups that who know where to seek targeted groups; endorse, safe treatment for STIs: 1992 = community surveys on behavior for 27.1% random samples of targeted reproductive health 1997 = 35%; 2001 = 45% groups 2003 = > 50% 1.2. Practice of safer 1.2. Percent of men who 1.2. Intercept interviews; 1.2. Counseling behavior for have used one condom ability to demonstrate the services will be reproductive health during the previous week: correct use of a condom; available among: (i) 1992 = less than I% focus groups of members of adolescents and 1997 = 4.5%; 2001 = 9% targeted groups; community Young adults (10 - 2003 = 12% surveys on random samples 24 Yrs old) (ii) of targeted groups Men and women of reproductive age 1.3. Grants support 1.3. Forty percent (40%) 1.3. Grantees' proposals and 1.3. Grants will be gender equity, of grants use funds to annual workplans; awarded by the reproductive and support and expand grantees' implementation Selection child health goals community based initiatives reports; project execution Committee and their promotion in reproductive and health and implementation reports; according to services, including safe targeted activities. motherhood initiatives. Project Appraisal Document Project title: Population and Reproductive Health Country: Guinea Annex 1: Page 5 of 15 2.1. Efficient 2.1. Over the project 2.1. Quarterly reports of 2.1. Regulatory and support services for duration, 75% of regional offices; training administrative Reproductive and reproductive and child modules; standardized arrangements to Child Health health practitioners in supervision reports; permit programs. priority areas, will provide observation of practitioners; decentralized care and services according adequate utilization of desk decision making to the norms, procedures references for care and will be issued. and guidelines. services; participation in Implementation of Quality Improvement Teams support to services is differentiated according to regional needs and will be sequential within each region. Monitoring and evaluation system permits to follow- up implementation and assessment of achievements in regions and prefectures. - Family planning 2.2. - a. By 2003, increase 2.2. Service statistics and 2.2. Affordable services; by 30% of the continuation tracer surveys of users; (subsidized) rate of contraceptive community survey, in-depth reproductive and practice among targeted interviews of providers and child health care groups beneficiaries, focus groups and services will be made available over the project duration. - HIV/AIDS 2.2. - b. Number of patients prevention services treated for STIs that are and seen at return visits - STI prevention and treatment services. 2.3. Increased client 2.3. - a. Increased number 2.3. - a. Routine service satisfaction and of births attended by statistics at community, increased number of trained providers: primary care and referral users of: 1992 = 35.8% levels; hospital admission 1997 = 40%; 2001 = 50% and obstetrical records 2003 = 60% Project Appraisal Document Project title: Population and Reproductive Health Country: Guinea Annex 1: Page 6 of 15 - Obstetrical 2.3. - b. Over the project 2.3. - b. Observation of services duration, at least 70% of clinical encounters; walk-out (Safe motherhood); respondents from targeted interviews; referral records; - Clinical child groups are satisfied with in-depth interviews of services the quality of IMCI mothers and care givers (Child Health) services: 1998 = <10 %; 2001 = 45 2003 = 70% 2.4. Decreased 2.4. - a. By 2001, 2.4. - a. Policy and strategy 2.4. a - Modalities number of practices Government will have put document of enactment or that are harmful to in place a policy framework enforcement of law women' s and strategy to eradicate prohibiting female reproductive tract female genital mutilation genital mutilations and health will be re-assessed to include activities such as "la reconversion des exciseuses" and "vacances sans excision". 2.4. - b. By 2005, decree 2.4.- b. Publication of decree forbidding FGM will be enacted. 3.1. C.N.P.R.H. will 3.1. By 2003, reforms of 3.1. Information packages 3.1 Weak have the authority population policy will be and reports of the three managerial and means to follow approved policy dialogue workshops; capacity of and coordinate the follow-up of Executive implementation of recommendations Secretary of population policy C.N.P.R.H. will be Publication of revised policy overcome. at the end of the phased program 3.2. The Population 3.2. Annual decentralized 3.2. Minutes of meetings, 3.2. The DCA and Health reviews of project program implementation and provides clauses to Coordination Office performances conducted as supervision reports; available ensure that the will facilitate the scheduled; annual AOPs PHCO will be at all oversight on and operations plans submitted times staffed with coordination of as scheduled professionals with executing agencies qualifications and by the Ministry of experience Health acceptable to IDA. Project Appraisal Document Project title: Population and Reproductive Health Country: Guinea Annex 1: Page 7 of 15 Major inputs by project Costs per Sub- Means of verification Critical component component assumptions m US $ [See Annex 2 for a detailed (component to description.] outputs) 1. 1. - Increased awareness 0.9 m US $ 1.1. - a. Database of trained The Population of population issues: advocates and activity reports; and Health training, calendar of sessions and activity Coordination production of messages for reports; follow-up of broadcast Office (PHCO) is small and mass media, calendar; recollection of messages staffed, equipped sessions by trained by targeted groups and functional. advocates and communicators Dissemination of main features of Population policy and related decrees among high ranking officials. 1.2. - Strengthened 1.6 m US $ 1.2. - a. Participants' lists for 1.2. Training of promotion of positive and training and activity reports of communicators, safer behavior: training of communicators, regional and promoters and youth peer leaders and prefectoral databases of providerswill providers, refurbishing and promoters, providers and commence when equipment of centres d' distributors, service statistics at managerial ecoute for youth, schools primary care and referral support and and University-based health facilities. material are services readily available. 1.3. - Improved equity and 1.1 m US $ 1.3. Reports of selection 1.3. Guidelines access to reproductive health committee; activity reports of and procedures of services for vulnerable funded NGOs fund management groups: financing of have been agreed grassroots activities and upon. local initiatives; strengthening of managerial capabilities of collaborating NGOs Project Appraisal Document Project title: Population and Reproductive Health Country: Guinea Annex 1: Page 8 of 15 2.1. - Improved 2.1 m US $ 2.1. Manual of procedures; 2.1. Involvement management of support orders and delivery logs at primary of decentralized services for Reproductive care and referral facilities; training health authorities Health: support records and functional databases of since the design decentralized management, personnel; regional and prefectoral phase. standardized supportive reports of physical inventories; -Fully functional supervision, quality reports of annual review meetings; regional assurance of care and reports of supportive supervision; warehouses in services, construction, review of random samples of Conakry and equipment, buffer stocks of records and annual operational Mamou essential drugs and plans. -Inventories at contraceptives, technical central level have assistance for improvement been compared of logistics, for training of with functional trainers inventories at decentralized implementation levels. -Technical assistance has been requested and provided on time. -Trained supervisors are assigned to and maintained in positions where they can apply acquired skills 2.2. - Improved quality of 2.1 m US $ 2.2. Prefectoral and regional 2.2. All providers and access to family reports on services. are aware that planning, STD/AIDS Annual operational plans; service Government has services: construction and statistics of University and school lifted legal barriers equipment of family based health centers. to sale and planning clinics, of selected Referral cards of promoters and advertisement of STI prevention and distributors; services statistics. contraceptives treatment and HIV/AIDS Review of random samples of -Timely completion prevention clinics; individual records of users; of civil works consumable for prevention community survey. -Quality of care of transmission, supervision Community survey; intercept started at delivery from prefectures and interviews. sites; standardized regions, quality supportive improvement activities at supervision is service delivery sites conducted to refine the assessment of training and supervision needs Project Appraisal Document Project title: Population and Reproductive Health Country: Guinea Annex 1: Page9of 15 -Management of contraceptives and essential drugs is functional from warehouse to service delivery site. -Providers understand and use data for micro planning and programmatic purposes 2.3. - Improved quality and 1.6 m US $ 2.3. Maternity admission record; 2.3. Involvement of utilization of Safe referral cards. communities in the Motherhood and Child Community survey with review of construction and health services: civil works, individual records of children daily operations of emergency obstetrical kit under five years old; activity maternity waiting and communication devices, reports. shelters. consumable, equipment and Referral cards; service statistics. furniture for maternity and obstetrical operating rooms and related facilities, supervision, micro planning of community-based activities, support for "Comites d'Hygiene Hospitaliere" and maternity quality assurance activities. 3.1. Provision of support to 0.9 m US $ Specimen of wall charts, booklets Technical CNPRH for the coordination and brochures in regions and assistance is of population policy; support prefectures requested and for dissemination of DHS provided on time. 1998 Final reports of DHS 1998 Project annual implementation reports 3.2. Population and health Coordination Office Project Appraisal Report Project Title: Population and Reproductive Health Country: Guinea Annex 1:Page 1O of 15 Attachment 1 to Annex I A. TRIGGER INDICATORS UNDER THE ADAPTABLE PROGRAM LOAN (APL) It is envisaged to implement the Population and Reproductive Health in urban and rural areas of Guinea in three phases. All phases will have the same development objectives. The first phase consists of launching fundamental regulatory and institutional frameworks, along with activities in priority domains, geographical areas and target groups. Building upon the accomplishments and successes of the first phase, the next and second phase would expand the coverage for reproductive and child health, and consolidate the quality of care and services, while simultaneously implementing operations research on financing mechanisms. The third and last phase would use the lessons of experience from previous phases to further strengthen sustainability and set the stage for the continuity of affordable quality reproductive and child health services. The project described in this PAD refers to the first phase of the program as described in the logical framework matrix in Annex 1. Each new phase would be submitted to an appraisal process aimed at evaluating the technical, economic, social and environmental feasibility, as well as incorporating experience gained during the implementation of the program. Trigger indicators will be assessed and measured as part of the monitoring and evaluation system in place and presented in evaluation reports prepared by each regional health inspection. During phase I, trigger indicators will follow the progress in capacity building and institutional strengthening so they will be more process-oriented. As the program advances, the emphasis will shift toward more quantitative trigger indicators. Project Appraisal Document Project title: Population and Reproductive Health Country: Guinea Annex 1: Page 11 of 15 Trigger indicators for Phase II (to be assessed by April 2002, as pre-requisites to appraisal) Assessing institutional Trigger indicators Means of verification framework and managerial capacity a) Involvement of setting regional committees for Regulatory texts issued; reports of population in program population and human resources, meetings of regional commissions. implementation at local with mandate and balanced level.. representation of institutions, NGOs and private sector and beneficiaries. The C.N.P.R.H.'s Executive Administrative decision and Secretary is operational and staffed. curriculum vitae of staff. Modalities of enforcement of law Action Plan available. prohibiting female genital mutilations will be adapted and finalized. Progress achieved in lifting legal Legal/regulatory texts issued.. barriers to sale and advertisement of contraceptives. b) Management of 1) Regulatory and administrative Regulatory texts issued; quality care and services arrangements are set to pernit administrative arrangements for reproductive and decentralized decision making for communicated through relevant line child health. personnel management, quality agencies. assurance of care and services and maintenance of assets, this includes: - members of QACS are nominated administrative text on nominations. for all regions and prefectures; - data on exhaustive evaluation of demonstration of databases and competencies, skills, potentials and reports, training plans needs are entered in databases maintained at regional level, and for each health region, the regional refresher training on Reproductive Health will be updated and transmitted to the Division of Reproductive Health - supervision techniques and supervision and QACs reports. protocols are standardized to allow comparisons within and across regions. Monitoring of QACS are issued. 2) a comprehensive plan to solve Action Plan discussed and issued.. current problems of the pharmaceutical sub-sector will be finalized. The plan will address the pricing policy, particularly the subsidizing of modem Project Appraisal Report Project Title: Population and Reproductive Health Country: Guinea Annex 1: Page 12 of 15 contraceptives so prices will not be a deterrent to consistent utilization. c) Local accountability -Annual operational plans are c) Regional and prefectoral activity for technical results in submitted and implemented on time. reports. population, reproductive and child health. -Monitoring and evaluation system permits to follow-up implementation and assessment of achievements in regions and prefectures. Indicative Triggers for Phase III (to be assessed by April 2006 as pre-requisite to appraisal) Project components Indicative triggers Means of verification a) Operations research Dissemination of results and scaling Research protocols; to test, adjust and up of chosen activities are included budget summaries expand sustainable in annual operational plans funding and financial managemen b) Expanding the Areas for expansion of Regional and prefectoral activity decentralized decentralization processes, and for reports management of RCH for introduction or strengthening of quality care and services QACS are identified soon after the mid-term review of the second phase c) Continuity of local Annual operational plans are Regional and prefectoral activity accountability for submitted in a timely manner and reports technical results in implemented population, reproductive and child health. Monitoring and evaluation system permits to follow-up implementation and assessment of achievements in regions and prefectures. d) Continuity of local Operational participation committees Community rapid assessment with participation in RCH meet as scheduled forms designed in collaboration with activities, including communities Early Childhood Development (for children born during Phases I and II) ECD services are provided by communities. Project Appraisal Document Project title: Population and Reproductive Health Country: Guinea Annex 1: Page 13 of 15 Attachment 2 to Annex I B. THE THREE PHASES OF THE PROGRAM Narrative summary COMPONENT 1: POPULATION Improve awareness of population issues and promote adequate / safer reproductive health practices Phase I (the project) Phase II: Phase III: Oct. 98-Dec. 2002 Jan. 2003-Dec. 2006 Jan. 2007-Dec. 2010 Initiation, setting frameworks Strengthening and expanding Ensuring continuity and sustainability Potential advocates are identified This second phase or the Communicators and peer and trained. Advocacy sessions Population component will counselors are active. Phase of geared towards officials and expand the number of ownership for the advocacy decision makers are carried out. individuals and groups involved program by opinion/cultural A first consensus building in advocacy and promotion of leaders. Active lobbyists for the through intersectoral policy safer behavior, and will deepen ban of F.G.M. Population and dialogue is reached. their knowledge of issues and development data are Collaborating NGOs and behavioral techniques. desaggregated by gender, on a communities identified by the Advocacy sessions will be routine basis, and regularly selection committee receive continued at regional and reported to decision makers at all support funds. Design, test and prefecture levels. A second levels. production of messages on small intersectoral policy dialogue will media and mass media are review achievements and Volunteers and distributors in started. Communicators are pending issues. Youth communities are able to redesign trained to inform various organizations, youth centers and as needed, with limited audiences through their youth gathering places will be assistance, behavioral change respective opinion leaders. rehabilitated or renovated and communication activities that Inventory and further assessment equipped. A second batch of meet their reproductive and child of youth organizations, youth collaborating NGOs and health needs. centers and youth gathering communities will be identified places will be carried out and and funded by a selection implementation plan revised committee. Mass media accordingly. Training of trainers campaign will be conductedon a of youth counselors, peer leaders bi-annual basis. Information and providers on education, sessions by communicators will motivation and counseling be resumed. Information and techniques will be organized. counseling services by youth counselors and peer leaders will be strengthened. Project Appraisal Document Project title: Population and Reproductive Health Country: Guinea Annex 1: Page 14 of 15 COMPONENT 2: REPRODUCTIVE AND CHILD HEALTH Improve quality of and access to services toward increased utilization Phase I (the project) Phase II: Phase III: Oct. 98-Dec. 2002 Jan. 2003-Dec. 2006 Jan. 2007-Dec. 2010 Initiation, setting frameworks Strengthening and expanding Ensuring continuity and sustainability Assistance is provided to set in Support services to maintain and - Advisory supervision from place the decentralization of expand reproductive health central level; supportive RCH programs, with full services, especially family technical supervision from decision making authority. planning and HIV/AIDS regional and prefecture levels are Support services for readily services, will be strengthened. funded through cost recovery available family planning and Rehabilitation of selected health mechanisms HlV/AIDS services are centers will be completed. All strengthened. Renovation of medical officers and health - Continuity of the QACS down selected health centers is carried managers will have completed to the community level. out and completed. Providers of the first series of training on readily available family planning Logistics systems in Mamou. - Regular and sufficient suplies services are trained in One-year buffer stocks will be of contraceptives and essential communication for behavioral available. University and school drugs changes (education, motivation based health centers will be and counseling). Repairs and restored and equipped. Skills of - Operational databases for staff replacement of elements of a second batch of providers on development in regions logistics systems are started. contraceptive technology will be Rapid needs assessment of upgraded during initial courses - 25% of women of University and school based of 4 weeks, graduation to the reproductive age residing in the health centers are completed and course will be highlighted by catchment areas of primary care implementation plan revised provision of minimum equipment are utilizing contraceptives. accordingly. Supervision and three to six months stocks. techniques are standardized to Assistance will be provided to - HIV/AIDS prevalence in the allow comparisons within a the three levels of health systems general population is stabilized region and across regions. to resume "supportive under 5% Assistance is provided to supervisory techniques". Divisions to train health National dissemination - All primary care centers are managers and medical officers in workshops of "Four-years of staffed with at least one midwife "supportive supervisory Quality Assurance experience" techniques". Quality Assurance will be implemented. Monitoring - Maternity waiting shelters are activities are started at national surveys will be carried out on operated by communities level; existing "comites relevant aspects of the program d'hygiene hospitaliere" are during the second year of the - Emergency Obstetrical assessed and supported to derive second phase. Standardized Services are available and and adopt a Guinean model of supportive supervision will be operational in 33 prefectures Quality Assurance. Surveys on carried out for facilities that are client perceptions of services are delivering reproductive health. conducted on random samples. Survey on client perceptions of Norns and procedures of services will be conducted on a reproductive Health are edited random sample. Dynamic according to categories of standard setting workshops will Project Appraisal Document Project title: Population and Reproductive Health Country: Guinea Annex 1: Page 15 of 15 providers or auxiliaries and be implemented at regional disseminated. Training needs of levels. Quality Assurance providers and supervisors are Committees are operating in completed. Training of trainers referral hospitals. Q.A on Contraceptive technology, on facilitators will be trained Integrated management of identified and trained. Quality Childhood Illnesses (IMCI) are Improvement teams will be conducted. Logistics of operating in Prefectoral Health contraceptives, essential drugs Directorates and in some of the and vaccines are supported. One health centers. All facility based -year buffer stocks is made providers in project areas will be available at the end of first year. trained on Contraceptive Medical officers and health technology and Integrated managers are trained on Management of Childhood Logistics systems in Mamou.. Illnesses (IMCI). COMPONENT 3: MANAGEMENT AND COORDINATION Strengthen the institutional capacity to manage and coordinate population and Reproductive Health Phase I (the project): Phase II: Phase III: Oct. 98-Dec. 2002 Jan. 2003-Dec. 2006 Jan. 2007-Dec. 2010 Initiation, setting frameworks Strengthening and expanding Ensuring continuity and sustainability The Executive Secretariat of the Continuation and adaptations of the - gradual devolution C.N.P.R.H. is responsible for the decentralized managerial processes. of elements of implementation of three policy programs to the workshops, modeling and projections regional level, through and dissemination of the 1998 DHS. It implementation of will also have the authority and means selected sustainability to follow-up and coordinate the procedures. implementation of population policies. -The Population and Health Operations research for sustainability - for activities with Coordination Office facilitates and at primary care level, for financing lower performances, coordinates the implementation of mechanisms at referral levels consultative project activities by executing workshops will be agencies of line ministries and carried out to analyze collaborating NGOs. issues, redefine -Decentralized management of strategies and plan the activities will be planned and required executed. Particularly, annual reviews improvements. of performances and operational plans will become recurrent managerial tasks that are scheduled and completed on "rain or shine basis" as to reduce time lags between submission of plans, requests for and allocation of resources and their utilization. Project Appraisal Document Project Title: Population and Reproductive Health Country: Guinea Annex 2: Page I of I I Annex 2: Detailed Project (phase I) Description The Population and Reproductive Health Project's development objective is to provide support to the Government of Guinea in its effort to prevent reproductive risks, illnesses and mortality by improving (1) awareness of population issues and promote adequate reproductive health practices; (2) quality, access and utilization of primary health care and priority reproductive health programs; and (3) institutional capacity to manage and coordinate population and reproductive health programs.. COMPONENT 1 - Improve awareness of population issues and promote adequate reproductive health practices: US$ 4.5 million (total cost of component). This component will ensure an environment that will be conducive to awareness and endorsement of main population and reproductive health issues by constituencies. Expected outputs will be: increased number of advocates who are decision makers, opinion and business leaders that will gaining the support of their peers and constituencies on issues considered; increased number of communicators that are promoting safer behavior among targeted groups. l .l. Increased awareness of population and development issues Description: The sub-component will support advocacy of population issues among various leaders and awareness of Population and Reproductive Health issues, including awareness of HIV/AIDS, in segments of the general population, mainly male heads of households, fathers, opinion, cultural and community leaders; adolescents and young adults and high ranking officials, managers of public and private sectors. Key messages of the programs will be disseminated either through both small media and mass media. Advocacy for "sustainable population growth" include the following activities: four national training workshops conducted by international specialists; thirty six (36) advocacy sessions in thrity three prefectures and three communes in Conakry; and five advocacy sessions per trained advocate. Information: will reach targeted groups through the following sequence of activities: three series of workshops on reproductive health themes for journalists and traditional communicators; thirty two (32) regional and one hundred and twenty (120) prefect6ral information sessions (4 themes per region or prefectures). The project will design, pretest and produce messages on small media and mass media, as well as annual information campaigns on reproductive health issues. Particularly, facts and information will be provided to cultural and religious leaders on Islam and fertility regulation, on use of modern contraceptive methods. Information on availability of Natural Family Planning activities will be made available to Christian Fundamentalists. Subsequent advocacy and awareness sessions and message designs will be programmed according to the results obtained from the monitoring activities. Project Appraisal Document Project Title: Population and Reproductive Health Country: Guinea Annex 2: Page 2 of II Financing: The IDA credit will finance for phase I, the totality of the activities described above. Investments include training of communicators and advocates; logistics of advocacy sessions; services for design, pretest and production of messages on small media; and with mass media support; logistics of information sessions; monitoring activities and at the end of the project and logistics of meetings to prepare the subsequent behavioral change communication (BCC) program. Behavioral change needs to be reinforced and renewed over time. For that reason, the second and third phases will resume the support of the same activities, but under slightly different conditions and design stemming from the assessment of the outcomes of the project. Implementation arrangements: The Ministry of Health, through its Division of Reproductive Health, will provide oversight on the overall technical quality of key messages for targeted groups. The specialist in charge of behavior change communication at the Population and Health Coordination Office (PHCO) will facilitate the decentralized implementation of training of advocates and communicators, of advocacy and information sessions, as well as annual information campaigns. Community, cultural and opinion leaders of targeted groups will be identified and selected by technicians from the "COFEG" and "Forum des ONG", according to specified criteria. At regional and prefectoral levels, under the guidance of "Governorats" and the technical leadership of regional health inspections, and according to the groups targeted for the sessions, the regional inspections of Women's Status, or the regional inspections for youth and social educational activities, will implement the local programme of sessions. Monitoring and evaluation activities will be carried out by local NGO of researchers, with technical services from similar international NGO as requested. Results will be used to further improve the efficiency of communication programs. 1.2. Increased promotion of positive and safer behavior Description: Target groups for the promotion of positive and safer behaviors will be: 2 million youth (10 to 24 years old) nationwide; the majority of Guinean men and women of reproductive age; parents and influential people of the communities: fathers and mothers, birth attendants, teachers and members of law enforcement corps. a) Activities for youth cohorts are designed to increase information, education and counseling services that are attractive and entertaining to in-school and out-of-school adolescents and to young adults, in urban or rural settings. The project will ensure the partnership of public agencies and donors for a nationwide standardized approach to behavior communication for youth. Behavior change activities for youth will include the following: technical training of youth educators, youth peer leaders and youth peer counselors by international specialists; provision of counseling services in "maisons des jeunes", "centres d' &eoute ", school health facilities and other youth gathering places; provision of referrals for clinical services designed to meet their specific needs and decentralized quarterly supervision of youth behavior communication activities. b) The second part of the behavioral sub-component will support behavior change process as to bring fathers and mothers, and men and women of reproductive age to make reproductive decisions, at the end Project Appraisal Document Project Title: Population and Reproductive Health Country: Guinea Annex 2: Page 3 of 11 of counseling sessions with trained providers. Target groups will be first fathers or male heads of household and influential people -- including traditional birth attendants and traditional healers, in communities around health centers supported by the project. Mothers of children under five years old and men and women of reproductive age are the other targeted groups for promotion of positive health practices. Mothers and caregivers of children between 5 - 10 years old are the main targets of Early Childhood Development activities. The following activities will be conducted under the project: training, by international specialists, of teams of trainers-supervisors who will in turn train first facility based providers of reproductive health care and, later, volunteer health promoters from each type of target groups; supervision of facility based health providers, community based health promoters and independent distributors in the following topics: basic inter-personal communication and counseling techniques; home visits for motivation, as well as topics related to family life education for rural and urban youth; population dynamics, STI, HIV and AIDS, Safe Motherhood, Community based Child Health and Early Childhood Development and Integrated Management of Childhood Illnesses (the latter is only for facility based providers). Financing: The IDA credit will finance the totality of the activities of this sub-component, which include training of trainers from central and regional levels; regional training of youth educators, counselors and health providers for youth; prefectoral training of youth peer leaders and health promoters and regional training of peer counselors and independent distributors. Training topics to be financed will be limited to the following: basic inter-personal communication and counseling techniques; home visits motivation techniques; family life education and contraception, population dynamics and reproductive choice; information services on gender issues and female genital mutilation; referral systems for emergency contraception and for STIs treatment services. The IDA credit will also finance logistics of information sessions; information and education materials (mainly referral cards with basic information, pamphlets, flyers, wall charts and posters, anatomic models and demonstration kits), refurbishing and equipment of "maisons des jeunes" managed by youth associations; refurbishing and equipment of "centres d' ecoute" in four prefectoral cities (Pita, Labe, Faranah and Kankan); of school based and University based health services in Conakry, Boke, Kindia, Mamou, Kankan, Faranah and N'zerekore; basic furniture for youth meeting areas in small towns and villages located near the four cities; and transportation for supervision as well as monitoring of activities and evaluation. Implementation arrangements: The DIEM at the Ministry of Health, in collaboration with the PHCO and consulting engineering firm ("Bureau d' Etudes") will be responsible for the refurbishing and renovations of the four "centres d' ecoutes", of school and university based health services, of procurement, reception and delivery of related medical equipment. The Division of Reproductive Health (DRH), along with the professional at PHCO in charge of behavior change communications will oversee the technical quality of key messages for targeted groups, the decentralized implementation of training, sessions and supervision, the procurement, reception and timely delivery of IEC materials to regional offices that are in charge of timely delivery to prefectoral health offices. At regional and prefectoral levels, under the guidance of "Governorats" and the technical leadership of regional health inspections, and according to the groups targeted for the sessions, the regional inspections of Women's Status, or the regional inspections for youth and social educational activities, will implement the local programme of communications for safer Project Appraisal Document Project Title: Population and Reproductive Health Country: Guinea Annex 2: Page 4 of 11 behavior and practices. Teams of prefectoral trainers-supervisors will be responsible for the training and supervision of facility based health providersas well as the supervision of health volunteers, of annual reviews of accomplishments, subsequent micro-planning and prefectoral annual operational plans. In collaboration with the DRH and the PHCO, the " Direction Generale des Radios Rurales et Comunautaires" will prepare and implement the mass media communication program for behavior change. Monitoring and evaluation activities will be carried out by local NGO of researchers, with technical services from similar international NGO as requested. Results will be used to further improve the efficiency of communication programs. 1.3. Improved equity and access to reproductive health services for vulnerable groups. Description: The sub-component is made of a Population Support Fund (PSF) to respond to specific needs of communities through a flexible funding mechanism. Priority grassroots programs related to population and reproductive health will be funded, as defined by beneficiaries, with assistance from indigenous NGOs. Activities that can be funded will thus vary according to local identification of needs. Guinean NGOs will be supported to implement various activities in relation to reproductive health such as training and communication for behavior changes, primarily opinion and behavior changes toward female genital mutilations; community based distribution of services and support for the creation or management of solidarity funds for Safer Motherhood ('MURIGA"); support to NGO and action committee to ban female genital mutilations; support to center for legal assistance to women and to the NGO of women in legal professions in order to enhance their informative role on rights to reproductive choice, status of the Family Code, and modalities of enactment of the law prohibiting female genital mutilation. Four (4) types of activities will be eligible under the grants: services of international specialists to assess the experimental phase of "clinics" of legal assistance to women; training in population and reproductive health activities, including management and training of trainers (up to 10%); extension of family planning through community based services (up to 35%); for the remaining 25%, improvement of women' s status, dissemination of "Guide pratique des droits de la femme" and community based safe motherhood initiatives. Matching grants at 75%, for the provision of 25% by communities, will be applied for the safe motherhood initiative. Financing: The IDA credit will finance grass root activities through matching funds; training in intermediate technology (to alleviate urban and rural women's workload); strengthening of managerial capabilities of collaborating NGOs; participatory techniques and cost recovery for Solidarity Funds; lobbying and advocacy techniques applied to legal matters; functional literacy and operational costs related to the management and monitoring of the Fund. Implementation arrangements: In collaboration with the Population and Health Coordination Office (PHCO), the Fund will be managed, according to the relevant sections of the project implementation manual, by a Selection Committee that is chaired by the representative of Ministry of Social Affairs. The selection committee will be responsible for overall quality of implementation of the PSF. The Selection Committee will have the following seven (7) members: one representative of Ministry of Social Affairs and Chair person of the Committee, one representative of the Ministry of Health, one representative of Ministry of Youth, Sports and Civic Project Appraisal Document Project Title: Population and Reproductive Health Country: Guinea Annex 2: Page 5 of 11 Education, one representative of Communication and Culture, one representative of women' s NGOs, one representative of "Forum des ONG", one representative of Ministry of Interior and Decentralization. The specialist in charge of NGO at the PHCO will provide technical support, secretarial functions and follow- up of the Committee's decisions. The Committee will send semi-annual activity reports to IDA. Coordination of NGOs for Women (COFEG) will ensure the coordination of the implementation down to the prefectoral level. Coordination of international NGOs in Guinea ("Forum des ONG") would ensure the monitoring and technical audits of supported activities. COMPONENT 2 - Improve quality and utilization of priority reproductive and child health programs: US$ 6.0 million (total cost of component) The design of Reproductive Health in Guinea had highlighted the unmet needs of segments of population, such as the youth cohorts and men of reproductive age, as it has also put forward managerial deficiencies of programs, particularly the lack of nationwide operational strategy for HIV/AIDS prevention and the slow expansion of family planning/contraceptive services and its limited access by Youth. This component will ensure that targeted beneficiaries will have access and continue the utilization of reproductive health services. 2.1. Rationalized management of support for Reproductive and Child Health services Description: The sub-component will support the capacity of national programs to execute decentralized priority reproductive health programmes. National programs will be supported in their capacity to provide advisory supervision to the eight regions; central level program managers and international specialists will jointly assist the eight regions in finalizing regional operational strategies, designing standardized supportive supervision modules, Quality Assurance module and training of national trainers , providers and auxiliaries on education and counseling techniques, contraceptive technology, and Integrated Management of Childhood Illnesses. By the end of the second year and after the completion of standardized supportive supervision by regions, a national training plan will be submitted at the coordination meeting of donor agencies. Further improvement of managerial processes of reproductive health program, through a differentiated and sequential implementation, that can be described as follows: first, the establishment of common managerial arrangements such as standardized supervision, quality assurance of care and services, functional logistic support systems and regular monitoring and coordination. The next step will be standardized timed sequences of implementation of quality clinical services, and safe practices among targeted groups. Annual review of achievements will be based on relevant, accurate, reliable and easily accessible data from population and reproductive health management information systems. The second component will support the country's eight administrative regions in their capacity to implement the five areas of the National Reproductive Health Programme. It will support the regional directorates in their tasks of coordination of technical programmes and managerial activities. Support at the regional level will include the following: quality assurance of referral and primary care services and community based distribution; upgrading the skills of providers, through training of trainers-supervisors and of providers, and later improving their performances through continuing supportive supervision, and quality improvement operations in prefectures and health centers. Capacity for management of logistics of contraceptives, essential drugs and vaccines at the three levels of health systems will be enhanced. At the prefectoral level, the project will address the managerial needs of prefectures in connection with Project Appraisal Document Project Title: Population and Reproductive Health Country: Guinea Annex 2: Page 6 of II capacity for essential drugs and contraceptives' logistics as to prevent shortages; timely preparation of annual workplans, budgets and supportive supervisory training of promoters, providers and independent (trained/licensed) distributors. By the end of the first phase, dynamic standard setting, procedures and regulations will be put into effect by at least 50% of facilities and providers. The second and third phases will continue the support for the quality assurance of care and services (QACS), in tenn of training and supervision. Financing: The credit will complement the financing provided by bilateral and multilateral agencies active in each region. Investment costs under the IDA credit will include: exhaustive assessment of competencies, skills and training needs of all providers, maintenance of functional databases of equipment, material and personnel at regional level, national workshops on standardized supportive supervision techniques, costs of first round of supervision of all primary health centers from the regions; regional workshops on Quality Assurance of Care and Services, production and dissemination of related modules, logistics of related training and supervision for providers, promoters and distributors in regions and prefectures. The IDA credit will finance the construction of, equipment and consumable for two regional warehouses in Conakry and Mamou; the remodeling of central EPI offices, repairs and replacement of critical elements of national EPI program, procurement of an EPI workshop truck to be based in Mamou, and a one year supply of STI and drugs for opportunistic infections, for IMCI as buffer / emergency stocks to be held in Conakry central warehouse, procurement of supply to prevent nosocomial infections in health centers, three (3) months buffer stock of contraceptives for central or regional levels and two (2) months for integrated health centers. The IDA credit will finance rehabilitation of, equipment and consumable for three prefectoral directorates of health that will be selected among the following: Kankan, Kouroussa, Mandiana, Dabola, Kerouane and Beyla. The IDA credit will finance vehicles and logistics of supervision from regions and prefectures as well as office and vehicle consumable for health regional inspections and prefectoral health directorates. Implementation arrangements: Within the Ministry of Health, managers of the five reproductive health programs at the Division of Reproductive Health (DRH), in close collaboration with the Population and Health Coordination Office (PHCO) and the regional health inspections offices, will be responsible for the oversight of technical quality of decentralized implementation of their respective programmes. The DIEM, in collaboration with the PHCO and consultant engineering firm will be responsible for the construction, rehabilitation and remodeling of facilities mentioned above. In partnership with representations of USAID, KfW- UJNFPA and UNICEF, the PHCO, central and regional managers of PEV/SSP/ME will be accountable for the procurement, storage, delivery and quality assurance of contraceptives, STIs, drugs for opportunistic infections and IMCI, and related equipment and consumable. The PHCO at the Ministry of Health will be accountable for the management of funds allocated to training, supervision, quality assurance activities. Regional health inspection offices will be accountable for the decentralized management of funds for training and supervision, under annually renewed accounting certifications by an independent firm acceptable to IDA. Regional inspection offices will be held accountable for annual reviews of Reproductive Health performances and subsequent planning and coordination. As is the case for other health programmes, prefectoral teams of trainers and supervisors are accountable for technical results of health centers and maternities. In collaboration with the PEV/SSP/ME program and prefectoral Project Appraisal Document Project Title: Population and Reproductive Health Country: Guinea Annex 2: Page 7 of 11 health directorates, the PHCO will ensure the timely procurement, reception and delivery of equipment, contraceptives, drugs and consumable, especially their issuance to trainees returning to posts of assignment. 2.2. Contraceptives, STD/HIV/AIDS, family planning services; Description: The sub-component will support the provision of culturally acceptable and yet medically safe contraceptive services, in facilities and communities. Services will be organized according to Quality Assurance techniques applied to standards (norms), procedures and guidelines that were defined by the Ministry of Health in 1996. Access will be increased by referrals to special service for youth, by community based volunteer health promoters. Volunteers and independent trained and licensed distributors will provide infornation and non medical services and refer beneficiaries who need long term methods to facility based practitioners. Follow-up of users will be done at community level by distributors on the basis of counter-referral notes issued during the visits at health facilities. Clinical practicum sites, facilities and independent distributors in the project areas will be assured of the regularity and quality of supply of contraceptives and essential drugs. The project will integrate contraceptive services in 15 existing health centers and will support the training of providers, the standardization of supervision of clinical services and set-up of quality improvement teams at delivery sites. The project will support monthly information sessions in cities where HIV/AIDS diagnosis and screening are available. The project will support operations research on sexual behavior, contraception and family planning practices in two model clinics (also practicum sites for training); and screening and treatment services of STD/HIV/AIDS, along with monthly information sessions, targeted to high risk transmitters at the following locations: Boussoura, Dixin Port, Boulbinet, army barracks in Conakry, and along the main routes and migration paths: Km36, Boffa, Kolabui, Tamagally, Marela, Sinkor and Banankord. These ten (10) specialized health posts (or "clinics") will be staffed by junior unemployed physicians and nurses (one physician and two nurses per site) who will be allowed to manage the facilities to earn minimum income, under the condition that they agree to periodically participate to training activities, operations research and studies needed by the Government, the PNLS and the project. Furthermore, on the other end of the continuum of HIV/AIDS care, the project will contribute to the installation of safe blood supply, the prevention of maternal child transmission (MCT) of HIV infection. During the remaining second and third phases, the IDA program will provide one-year of buffer stock for essential drugs and contraceptives, and will put in place mechanisms to ensure the continuity of quality sustainable services. Financing: In this first phase, the IDA credit will finance the construction of equipment, contraceptives, essential drugs and consumable for two model clinics, the rehabilitation and renovation 15 health centers, the rehabilitation of selected school and university based health services and the procurement of start-up kits for independent (trained/licensed) distributors. The IDA credit will finance the training of prefectoral teams of trainers-supervisors, training and supervision of providers and auxiliaries in education and counseling techniques, contraceptive technology, syndromic approach of STI diagnosis and treatment and prevention of HIV/AIDS. With regards to groups of high transmitters, the IDA credit will finance construction, equipment, STI drugs and consumable for 10 specialized health posts, as well as the training and supervision of independent practitioners recruited among junior unemployed physicians and nurses. Project Appraisal Document Project Title: Population and Reproductive Health Country: Guinea Annex 2: Page 8 of 11 The IDA credit will finance the rehabilitation and equipment of the national referral laboratory for HIV/AIDS and the equipment of regional laboratories for screening of HIV/AIDS (Kindia, Mamou, Labe, Kankan and N'zerekore). Implementation arrangements: The Division of Reproductive Health (DRH) at the National Directorate of Public Health, at the Ministry of Health will be responsible for the overall technical quality of care and services, of training and supervision of practitioners and distributors. The DIEM, in collaboration with the PHCO and consultant engineering firm will be responsible for the construction and rehabilitation of two model family planning clinics and 10 specialized health posts. The DIEM and the Division of Logistics, with the PHCO in coordination with other donors (KfW, UNFPA and USAID), will ensure timely procurement, adequate storage, and quality assurance of contraceptives, drugs, equipment and consumable. The PEV/SSP/ME program at the Division of Logistics, in collaboration with prefectoral health directorates, will be responsible for adequate storage and timely distribution and delivery of contraceptives, drugs, equipment and consumable to facilities.. While the eight Regional Health Inspections Offices will be responsible for the execution of decentralized family planning, STI treatment and STI/HIV/AIDS prevention programmes, the 33 Prefectoral Health Directorates will be responsible for the implementation of quality assurance of care and services (QACS) through standardized supervisory training and follow-up on delivery sites of quality improvement teams (QIT). Practical training for Family Planning will be sub- contracted to AGBEF in locations with high den;ty of clients such as Kindia, Labe and Kankan. Practical training for syndromic approach of treatment of STIs and prevention of HIV/AIDS will be conducted in the 10 specialized health posts. Practitioners based at primary care facility will provide reproductive health services to individuals, couples and families referred by volunteer health promoters and independent distributors. Practitioners and distributors will be responsible for annual micro- planning, with assistance from prefectoral health directorates. 2.3. Safe Motherhood and Child Health services; Description: This sub-component will address Safe Motherhood and Child Health as follows: 2.3.1. Emergency Obstetrical program will include: training of obstetricians and their teams in Essentials of Emergency Obstetrical Care (EEOC); prevention of maternal and child transmission (MCT), prevention of transmission and contamination in health care setting; improvement of maternity working conditions and environment through Quality Assurance Committees ("Comites d' Hygiene Hospitaliere"); improvement of safety of blood transfusion; inventory of needs and resources for Safe Motherhood of isolated villages and communities in underserved prefectures, by using "active participatory research" or participatory research appraisal (PRA) techniques; training of volunteer health promoters to the following: early screening of risks and danger sign during pregnancy; early detection of risks and signs of complication during childbirth; community organization for solidarity funds for Safe Motherhood ("MURIGA"), periodic communication with health centers and transportation to nearest emergency obstetrical services. 2.3.2. Prevention of malnutrition and community based early childhood development services will include: inventory of needs and resources in villages collaborating with the program; logistical support to collaborating NGOs, or to local schools involved in early childhood development activities. Project Appraisal Document Project Title: Population and Reproductive Health Country: Guinea Annex 2: Page 9 of 11 2.3.3. Integrated Management of Childhood Illnesses will take place at primary care and referral facilities. Support provided during the first phase will include: training of trainers and providers of IMCI services and provision of essential drugs and support for supportive supervision of care and services. Financing: The IDA credit will finance the construction of the prefectoral maternity of Kankan, the rehabilitation or renovation of operating theaters, intensive care units and post operative wards in the 8 most underserved prefectures of Koundara, Gaoual, Siguiri, Beyla, Mandiana, Dinguiraye and Lola, and 10 maternity waiting shelters to be located next to referral obstetrical services. The IDA credit will finance vehicles and other emergency transportation, radio communication devices and emergency obstetrical kits, as well as drugs and consumable to prevent transmission and contamination. The IDA credit will finance behavior change communication for Safe Motherhood from the 33 prefectoral hospitals, training of prefectoral teams in Essential Obstetrics (including emergency obstetrics), training for QACS in hospital setting, training for community organization for solidarity funds for Safe motherhood ("MURIGA") and supervision of prenatal care and obstetrical services in health centers and communities. The IDA credit will also co-finance with UNICEF and WHO activities pertaining to prevention of malnutrition and training and supervision in IMCI for under five years old. Implementation arrangements: At the central level, the Safe Motherhood Program at the DRH, with assistance from the PHCO will oversee the technical quality of decentralized Safe Motherhood activities. While the eight Regional Health Inspections Offices will be responsible for the execution of decentralized Safe Motherhood and Child Health programs, the 33 Prefectoral Health Directorates will be responsible for the implementation of quality assurance of obstetrical care and services (QACS) through standardized supervisory training and follow-up of quality improvement teams (QIT). An academic institution will collaborate with COFEG for the implementation of the "MURIGA" in spontaneous localities (shanty towns) around Conakry and in underserved prefectures. Prefectoral Health Directorates will collaborate with UNICEF for the training of village birth attendants, with WHO country teams for the implementation of IMCI training and supervision. COMPONENT 3. - Strengthening institutional capacity to manage and coordinate Population and Reproductive Health Programs US$1.5 million (total costs of component) This component will ensure and foster a policy environment that is conducive to policy dialogue, policy changes and awareness of main population and reproductive health issues by constituencies. Expected outputs of the component encompass policy reforms and program decisions stemming from increased consideration of reliable, accurate and up-to-date information; better coordination of programs funded by various donors; incremental increases of Government's share of recurrent costs for Population and Reproductive Health Programs and timely implementation, at all administrative levels, of common and recurrent managerial tasks pertaining to the national reproductive health program. 3.1. Strengthened institutional capacities to better manage population programs Description: The purpose of this sub-component is to foster and maintain the coordination of population programs and to promote informed decision making at executive and at implementation levels. The sub-component will Project Appraisal Document Project Title: Population and Reproductive Health Country: Guinea Annex 2: Page 10 of 11 provide accurate data in the form of executive briefs, regional and prefectoral updates of social trends, and special reports on an as needed basis. Activities to be conducted under the sub-component include: three policy dialogue workshops; modeling and projections of economic and population growths vis-a-vis the AIDS epidemic, youth and the labor market; on-the -job training of Guinean statistician- demographers; graphic treatment and dissemination of the results of 1998 demographic and health survey (DHS98). Financing: The IDA credit will finance the renovation, computerized workstations, equipment and furniture for the Executive Secretary of the National Committee for Population and Human Resources ("C.N.P.R.H."). The IDA credit will finance the graphic treatment and dissemination workshops of the DHS98. Implementation arrangements: The implementation of civil works financed by the IDA credit will be delegated to the DIEM at the Ministry of Health, in collaboration with the PHCO. Installation of the computerized information systems in their renovated prepared locations will be contracted out by the PHCO. Regular maintenance of the computerized equipment will be the responsibility of the supplier or its, local representation. Professional staff of the PHCO will provide technical assistance to the Executive Secretary for the three policy dialogue workshops and on as needed basis. 3.2. National coordination of Population and Health Description: Coordination of the project's execution will mostly consist of the coordination of allocation of resources, oversight of technical activities conducted by institutions and collaborating NGOs, annual and mid-term reviews, and national plans of operations. Coordination and oversight tasks will be carried out by national professional staff with the following skill mix: management of reproductive health services; statistics and demography; economist; rural sociology and community organization and participation and behavior change communications (please confer to job descriptions in Annex of the Project Implementation Manual). Financing: The IDA credit will finance during the first phase of the program the totality of coordination activities for population and reproductive health. The IDA credit will finance the rehabilitation of the facility for PHCO, and the offices of eight (8) prefectoral health directorates. The IDA credit will also finance the office equipment, office consumable, vehicle and consumable of PHCO; installation, operations and maintenance of office equipment, as well as the wages and benefits of PHCO recruited professional and support staff. The IDA credit will also finance consultancy services, long term training in Epidemiology and short term training in management of drug supply. During phase II and III of the program, Governement's leadership for coordination will be translated into an increased share of financing of coordination activities. Project Appraisal Document Project Title: Population and Reproductive Health Country: Guinea Annex 2: Page 11 of 11 Implementation arrangements: The PHCO at the Ministry of Health will be involved as follows: 1 - Management of funds allocated to training, supervision, quality assurance activities; annual renewal of accounting certifications of regional health inspections offices. 2 - Joint supervision with the DIEM of the consulting engineering firm ("Bureau d' Etudes") responsible for the refurbishing and renovations of the four "centres d 'ecoutes", of school and university based health services and of procurement, reception and delivery of related medical equipment; for the construction, rehabilitation of two model family planning clinics and 10 specialized health posts; and joint supervision with the DIEM of the consulting engineering firm for the renovation of the offices of the Executive Secretary of C.N.P.R.H. 3 - Coordination with the DIEM and the Division of Logistics at the Ministry of Health (i.e. PEV/SSP/ME program), in collaboration with other donors (KfW, UNFPA and USAID), of timely procurement, adequate storage, and quality assurance of contraceptives, drugs, equipment and consumable. 4 - Overall quality of behavior change communications, decentralized implementation of training of advocates and communicators, of advocacy and information sessions, as well as annual information campaigns; technical quality of key messages for targeted groups, the decentralized implementation of training, sessions and supervision, the procurement, reception and timely delivery of IEC materials to regional offices that are in charge of timely delivery to prefectoral health offices. 5 - Technical assistance to the Executive Secretary for the three policy dialogue workshops and any task on an as needed basis. 6 - Technical support, secretarial functions and follow-up of decisions of the Population Support Fund Committee, including semi-annual activity reports to IDA. 7 - Oversight of technical quality of decentralized family planning services, prevention and treatment of HIV/STIs, school and University based services, emergency obstetrical services and community based Safe Motherhood activities. Project Appraisal Document Project Title: Population and Reproductive Health Country: Guinea Annex 3: Page I of I Annex 3: Estimated Project' Costs Local Foreign Total -----------------------US $ million-------------------- Project Components l'opulation Awareness, Safer 1.42 2.63 4.05 Behavior R.H. Quality Services 1.89 3.51 5.40 Institutional Capacity 0.48 0.88 1.36 Total Baseline Cost 3.79 7.02 10.81 Physical Contingencies 0.15 0.28 0.43 Price Contingencies 0.27 0.49 0.76 Total Project Cost 4.21 7.79 12.00 Project Appraisal Document Project Title: Population and Reproductive Health Country: Guinea Annex 4: Page I of 10 Annex 4: Guinea: Population & Reproductive Health Project Economic Analysis I. Introduction 1. Country context. Over the past five years, Guinea has made significant progress in achieving a moderate but steady rate of economic growth averaging 4.5 percent per year within a stable macroeconomic environment characterized by declining fiscal and external deficits. However, actual results on the ground in terms of higher per-capita income and poverty reduction were poor: 52 percent of Guineans currently live below the poverty line. This situation is the result of a rapid growth of the country's population (3.2 % per year) whose overall health status is equally poor. The 1994 Cairo Conference gave the authorities the opportunity to initiate the implementation of already prepared and adopted sectoral strategies to deal vigorously with the issue of population and reproductive health. This project, a product of an intensive dialogue with the authorities and stakeholders through studies and workshops, supports this strategy; its development objectives are to support the Government's effort to: (i) improve awareness of population issues and promote adequate reproductive health practices; and (ii) improve quality, access and utilization of primary health care and priority reproductive health programs. 2. Objectives. The main objectives of this analysis are three-fold: (i) to provide the economic rationale for public intervention; (ii) to demonstrate that the project design is appropriate and supports cost-effective and affordable activities; and finally (iii) to demonstrate that the project contributes to poverty alleviation, but does not crowd out the private sector, and adds net benefit to the national economy. In addition to the results of numerous studies, workshops and official documents such as the Medium-term Development Strategy (Vision 2010), the Population Policy, and the Health Sector Development Strategy, this analysis is based on extensive Economic and Sector Work such as the Poverty Assessment (Report No. 16465-GUI), the draft Public Expenditure Review (Report No. 15147-GUI), the President's Report of the Public Expenditure Management Adjustment Credit (PEMAC, Report No. P7198-GUI), and the Country Assistance Strategy (CAS, Report No. 17183-GUI). HI. Macroeconomic framework 3. Economic performance. On most accounts, Guinea is classified as one of the poorest countries in Africa, with a per-capita GDP estimated at $US 535, life expectancy at birth at only 45 years, and a high illiteracy of some 80 percent amongst the adult population; yet the country is richly endowed with agricultural, mineral and energy resources. This disastrous situation is blamed mostly on past policy failures encompassing over 20 years of centralized command-type economic management which the authorities have been engaged in undoing since 1986. The first round of reforms produced encouraging results; but as the law of diminishing marginal returns started to take hold in the face of more deep-rooted and politically sensitive reforms, the second round of reforms was characterized by uneven implementation. Overall, the performance of the economy in recent years has been satisfactory. GDP growth inched closer to the 5 percent target; to compensate for foreign exchange shortfalls due to the decline of bauxite and aluminum prices on the international market, both fiscal revenues and exports from non-mining activities have increased; much was done to contain inflation which fell from 20 percent in 1990 to 3.6 percent in 1996. Project Appraisal Document Project Title: Population and Reproductive Health Country: Guinea Annex 4: Page 2 of 10 III. Main Sectoral Issues 4. Reference. Please report to the main text for more details on the main issues to be addressed by the project and strategic choices (Block 2, para. 7). Nevertheless, the following background and issues are highlighted from an economic and financial perspective. 5. Population. With some 75 percent rural dwellers, the population is estimated at 7.2 million as of mid- 1996. Youth population under 15, women of reproductive age (15-49), and children under 5 account for 45, 25 and 18 percent, respectively. Implementation and monitoring of population programs are deficient in supporting youths' behavioral change (IEC) in relation to reproductive choices, age of marriage and gender. With close to two million women entering their fertile years which will span over the next 30 years, the risk of a "population momentum" has never been greater with its potential negative impact on socio-economic infrastructures. 6. Provision andfinancing of health care. The modem health care system employs some 980 medical doctors; it is predominantly public (94% of doctors). The Ministry of Health is responsible for formulating, planning and managing sectoral policy; it discharges these functions through its technical directorates for population and health programs, administration, finance, and planning. Increasingly, these functions are also being carried out by decentralized regional health inspectorates and district health directorates. Many health centers have now adopted cost-recovery schemes, whereby fees are collected for health services, especially the prescription and direct provision of drugs. Some 53 percent of public hospital have a rate of cost recovery of non-wage expenditures of 50 percent or more (DNES, 1995). Main sectoral issues are: => A globally underfunded health care system: Despite the Government's effort to protect health care funding in the past five years, the overall resources allocated to the sector remains largely insufficient. Moreover, real health spending has declined at an alarming rate in recent years from US$7 to about US$2-3 in per-capita terms over the 1988-1996 period; => Inequitable resource allocation with an urban bias: Access to health services exhibit large geographical and income-related disparities as a result of a highly skewed allocation of public resources in favor of urban hospitals which consume over three fourths of budgetary spending with 90 percent accruing to wages and salaries; this misallocation leaves non-wage recurrent expenditures insufficient and limits the effectiveness of the health care system; > Inadequate coverage of the poor: As health care is income elastic, wealthier groups access the health system and benefit from it far more than the poor. Besides the affordability factor, low demand of public health care is mainly due to low coverage, poor quality of service, especially health providers' inadequate behavior. More than cost recovery fees, the travel and waiting time is a deterrent to seeking modem treatment, explaining why over 60 percent of the poorest quintile of the population do not seek needed services (IHS data, 1994); > Weak institutional and referral capacities: To a large extent, most health districts are not equipped to implement their mandate pertaining to management, training and supervisory functions of health centers. In addition, roles and responsibilities for management and decision-making are either ill- defined or overly centralized, especially with regard to effective allocation of resources. Though formal entry into public health system is at the sub-prefectural level, many non-primary health establishments often diagnose and treat primary ailments. Referral rates from health centers to Project Appraisal Document Project Title: Population and Reproductive Health Country: Guinea Annex 4: Page 3 of 10 hospitals are extremely low at about 1 percent. This has resulted in a low utilization rate of 25 percent for primary health centers in Conakry and in most of other urban areas, reflecting the availability of hospital care. 7. The Private Sector. Private sector provision and financing of health services is very limited. It is comprised of a large informal sector in villages and small cities that consists of an unknown, but likely important, number of traditional medicine practitioners along with a small formal sector that employs about 57 medical doctors and dentists, 51 nurses, and 128 pharmacists, all located in cities. Privately- funded medical insurance is practically non-existent; only the "Caisse Nationale de S&curitk Sociale" (CNSS) provides limited health benefits to participants and their immediate family. However, a large number of traditional risk-pooling mechanisms (ie. Tontines, Mutuelles, Sere) exist to assist community members in need. As they all entail the payment of some kind of premium, these mechanisms are likely to exclude the poorest segment of the population. IV. Rationale for Public Intervention 8. Characteristics of the health sector. Due to asymmetric and imperfect information, limited access of low income households to services and moral hazards generated by special interest groups, the health sector is characterized by a variety of market failures that justify public intervention. This is the case especially for low income countries such as Guinea where basic socio-infrastructures and private initiatives are embryonic. What follows fully justifies public intervention in the areas of population and reproductive health in Guinea: => Public goods. Activities financed by the project comprise population programs and public health interventions such as: (i) media-based information campaigns on STIs and reproductive health; (ii) vaccination and wide-area control of disease vectors that are well targeted actions to protect mothers and their infants; and (iii) readily available scientific information for policy formulation, planning and monitoring. One individual can use these interventions or benefits from them without limiting other's consumption or benefit; and as long as someone pays, everybody benefits. They are known as public goods for which only the Government can ensure provision; => Externalities. Individual pricing and demand for numerous basic health interventions is often not influenced by the risk of infecting others. For example, curing an individual of tuberculosis or of a mild and asymptomatic STI also prevents the transmission of the disease. If these spillovers of benefits to others is not taken into account, treatment will be priced too high in the private market and insufficient treatment of the illness will be taken. Only a global evaluation of economy-wide benefits to society can reveal the high cost-effectiveness that justify public sector intervention. The project focuses exclusively on this kind of health care service; = Poverty alleviation. Reducing absolute poverty requires the enhancement of labor productivity -- the most abundant asset of the poor -- and an increase in human capital. Increased access to basic health care, education -- especially in the area of population dynamics and reproductive health, and better nutrition are the most cost-effective and quasi-universal means to win the fight against poverty. By increasing investment in the health of the poor, the project is supporting an economically efficient and politically acceptable strategy for reducing poverty and alleviating its negative consequences. Improvement in maternal health and nutrition increases the survival chances and well-being of children; and this in turn leads to lower fertility levels. Declining fertility is likely to generate a positive impact on the environment and economic gains for the existing and future generations. Typically earning less than US$1 per day in real purchasing power, most of the Guineans in rural Project Appraisal Document Project Title: Population and Reproductive Health Country: Guinea Annex 4: Page 4 of 10 areas can neither afford much health care, nor borrow to pay for it. Thus, the redistributive function of the state is called for to reduce the inequity in society by lowering the burden of disease and fertility among poor women and children, thereby enabling low income households to participate in productive economic activity; => Support to private sector initiatives. Although public sector intervention is both predominant and justified in Guinea's health care system, the private sector has an important role to play in the areas of IEC and delivery of clinical services. A key medium-term objective is a gradual increase of private provision of basic clinical services. Public interventions should focus on: (i) subsidizing of core health services that actually reach the poor; (ii) organizing public sector structures and activities to support the private sector; (iii) strengthening the institutional, judicial and regulatory framework; and (iv) ensuring professional and quality excellence through accreditation and competition. The participative and consultative approach embraced by the project has allowed the identification of complementary activities regarding private sector initiatives and existing donor programs (UNICEF, USAID and UNFPA). Project implementation will rely heavily on local communities and NGOs that interact with beneficiaries on a daily basis. V. Appropriate Form of Intervention 9. Choice of interventions. Justification of public intervention is only part of the story, the right choice of interventions as well as the proper level of provision of any public good require careful analysis of the expected health benefits in relation to the costs (see cost-effectiveness analysis below). To ensure that subsidized population and health services actually reach the poor, programs must be properly targeted to beneficiaries and restrictions may be necessary for the kind of care that is paid for by the public sector. For example, offering free care of all types to everyone leads to geographic or quality- based rationing of services; such universal programs may not usually reach the poor or improve their health status. In order to make optimal choices for interventions, project objectives have been determined by a participatory approach and community empowerment as described below. 10. Participatory approach. Project identification and preparation have been guided by an extensive participatory and consensus building approach which included: (i) holding throughout the country more than 20 consultative seminars involving representatives of primary beneficiaries and local NGOs, civil service managers and opinion leaders; (ii) the use of national consultants to carry out a number of studies and surveys; and (iii) a core team of national experts to serve as a technical advisory body. Following this consultative and facts finding phase, a workshop (based on ZOPP methodology) was held to define the appropriate project design. Such a participatory approach has successfully ensured that project content reflects most of the concerns of stakeholders and partners, and that its objectives are considered as key development priorities for Guinea. Based on the results of these grassroots consultative meetings, the Government has also identified three additional priority areas (namely education, agriculture and rural development, and road maintenance) which, along with health, will benefit from the Bank-supported Public Expenditure Management Program (see PEAIAC, para. 2). VI. Economic and Sector Linkages 11. Links to the CAS. The overarching goal of long-term development highlighted in the Country Assistance Strategy (CAS) is to improve the well-being of the Guineans by ensuring efficient delivery of social services, especially in rural areas, and by promoting private sector-led growth and employment. Consistent with the CAS's social development objectives, the project supports the highly intertwined population policy and the national health strategy. In the area of population, the project seeks to Project Appraisal Document Project Title: Population and Reproductive Health Country: Guinea Annex 4: Page 5 of 10 contribute to the alleviation of poverty through improving the well-being of the population by gradually increasing the use of contraceptives which, in turn, will lower the total fertility rate and reduce population growth. As for the health care system, the Government's overall objective is to improve the quality of and to expand the coverage of primary health services, especially those targeted towards the vulnerable population of rural women and children. As noted earlier, the project is based on the findings of numerous sector studies and workshops which have confirmed its objectives (see para. 2). 12. Community participation and private sector development. Improvement of basic economic and social infrastructures in rural areas with a strong community participation is a key component of the Government's strategy to attract private investment and facilitate development in these areas. Achieving results on the ground would provide an answer to the politically sensitive problem of "rural exodus" to urban agglomerations and the ensuing high level of urban vanguards and youth unemployment. The availability of basic economic infrastructures in rural zones would gradually increase productivity, raise rural incomes and provide major incentives for private sector provision and financing of health services in those areas. In the medium-term, the public sector role in rural basic service delivery may need to be re-evaluated to avoid the potential for crowding out the private sector. I. Alternatives Guiding Project Design 13. Reference. Please refer to the main text (Block 2, para. 8) for four project alternatives considered and reasons for rejection. They include (i) an exclusive contraceptive and STI/HIV/AIDS prevention project; (ii) a project with a stronger family planning "IEC" component; (iii) a maternal and child health and family planning project; and (iv) dividing project components into separate sub-projects that are designed and implemented by the Ministries of Plan, of Social Affairs and of Health. 14. The Status-Quo. In addition to the above alternatives, the status-quo is a possible alternative to be considered. As illustrated in section III (main sectoral issues), maintaining the status-quo would likely result in a "population momentum" with an explosive growth which would, in turn, undermine the effort to create basic economic and social infrastructures in rural areas; low income consumers in those areas would not gain access to reproductive health services; the lack of information and meaningful community participation would continue to hamper rational decision-making by consumers; and more importantly, the quality of health services, particularly at the primary level, would suffer since preventive and promotional level services such as family planning and nutrition education or immunization of under five years would continue to be supplied below socially optimal levels. All such outcomes would worsen the already poor health status of the population, and absolute poverty would drastically increase throughout the country. VIII. Fiscal Impact and Cost Recovery 15. Patterns of resource allocation. Difficulties in expenditure reallocation in the past five years have created discrepancies between the stated official policy of increasing public spending for primary health care to combat the most prevalent diseases and actual patterns of resource allocation. Total expenditure for primary care averaged less than a quarter of total spending; official policy to redeploy health personnel to the primary care positions has yet to materialize since the latter accounts for less than a third of total wages and salaries; and finally, the dismal share of non-wage in total spending makes infrastructure and vehicle maintenance -- vital means for reaching the poor in remote areas -- rather tenuous. In the past 4-5 years, total budgetary expenditures for health services have averaged GNF37.6 billion, accounting for 6.2% of total public expenditures. In terms of investment financing, the BND for Project Appraisal Document Project Title: Population and Reproductive Health Country: Guinea Annex 4: Page 6 of 10 health amounted to about GNF 4.9 billion (13.1% of health investment). Community participation, coupled with cost recovery for selected hospital services provide a viable short-term solution while a more aggressive expenditure reallocation policy can be designed and implemented. 16. Fiscal impact. First, budgetary counterpart funds needed are estimated to amount to GNF2.0 billion (0.5% of public investment) over the next five years. Second, annual recurrent expenditures arising from project implementation are expected to average GNF577 million (0.1% of recurrent budget). These are not expected to impose a major fiscal burden. Though Guinea has initiated cost recovery at almost all levels of the health system (Bamako Initiative), a more aggressive action in that regard is perhaps unnecessary before a viable program to protect indigent patients is firmly in place. Moreover, such an action is likely to put significant stress on the poor and dampen low income households' demand for health care services. 17. Financial sustainability. Under a rather conservative growth and budget outlook over the next decade, public health expenditures would increase gradually (along with other priority sectors identified by the PEMA4C) from 6.3 percent of budgetary spending in 1996 (1.1% of GDP) to 8 percent by 2005 (2% of GDP), and reach around 10 percent by 2010 (2-3% of GDP). In order to create the basis for sustained growth, the overall public investment budget would increase from 8.6 percent of GDP in 1997 to reach and stabilize at about 10 percent by the year 2005. Though increasing, the investment-related recurrent budget remains manageable under normal revenue assumptions which exclude severe terms of trade shocks. However, ensuring a financially viable system in the long term will require a more coordinated action from all development partners within an adequate public expenditure framework. Such a program will in turn require a well-coordinated sector-wide approach. As noted earlier, the widespread community support for the absolute poor, in addition to the spectacular development of numerous traditional risks pooling mechanisms in the community augur well with the financially sustainable set of population and reproductive health activities financed by the project. IX. Cost effectiveness Analysis 18. Purpose. The purpose of the cost-effectiveness analysis is to show that the project supports efficient health interventions in terms of net gain in health or reduction in disease burden in relation to costs. It has some limitations such as failing to provide a direct analytical basis for dealing with decentralization, drug and services delivery, and quality of care. Numerous studies and analyses have demonstrated that the major causes of premature death in Guinea (communicable, maternal, and perinatal diseases) are subject to highly cost-effective interventions. The 1993 WDR (Investing in Health) defined a cost-effective intervention as one where the cost per DALY (Disability-Adjusted Life Years) saved is below US$250; Interventions with cost per DALY gained below US$100 are classified as highly cost- effective. 19. Project interventions. Analysis of the cost effectiveness of the interventions financed by the proposed project falls into two broad categories. First, the concept of the US$ cost per DALY saved is utilized to compare the cost effectiveness of overall interventions such as ante-natal care and immunization to other interventions in the health sector; and second, the notions of couple years of protection (CYP) and number of births averted are used to analyze the cost effectiveness of alternative forms of service delivery for a number of reproductive health interventions. Finally, the set of interventions supported by the project are compared with recommendations from cross-country studies such as the 1993 WDR and "Better Health for Africa, 1994". Following a standard practice, project interventions have been grouped into 5 categories in table 2 below. The last column is of particular Project Appraisal Document Project Title: Population and Reproductive Health Country: Guinea Annex 4: Page 7 of 10 importance since it gives the cost effectiveness indicator for each population activity, reproductive health intervention and institutional support thereof. The five categories of rating range from high (H) to low (L) cost effectiveness (CE). 20. Cost per DALY saved. Extensive use was made of the results from country-specific studies (i.e. Guinea, Mozambique, India, etc.) as well as cross-country studies (WDR 93 and BHA) to classify the non-capacity building interventions; available literature has yet to evaluate the cost effectiveness (most likely high) of institutional development and support services. While basically all the sources agree on the rating, estimated cost per DALY saved vary among countries with Guinea ranking often the highest. For example, the average cost per DALY saved through the Extended Program of Immunization (EPI) for low income is estimated to be on the order of US$12 (i.e. the same for Mozambique), while the Guinea- specific study came up with US$25 [Jha, 1996]. The results presented inAppendix I indicate that about 90 percent of measurable project interventions are highly cost effective, and none falls into the low cost- effective category. 21. Family Planning. A country-specific study on the cost effectiveness across contraceptive methods (measured in terms of couple year of protection or number of births averted) is not available. However, similar studies have been conducted in India and several Asian and Latin American countries. Though across country comparisons are fraught with problems, sterilization has come at the top of ranking because it involves a single operation and the effects are permanent. Due to market segmentation, various methods do not actually compete. For example, sterilization cannot help younger couples who wish to limit the number of children and control the spacing of births but who are certainly not ready to end childbearing. Thus the project will support a greater choice of contraceptive methods without systematic recourse to terminal (or hard to reverse) methods. Cost per births averted ratios and costs estimates conducted by the UNFPA in several countries gave the following results for clinical-based family planning services. Under the assumption that the cost of the same services are higher in Guinea by some 10-15 percent, they still represent an affordable way to improve the livelihood of millions of young rural couples with "unmet contraceptive needs" and their children. Table 1. Comparative benefit and cost of selected FP Interventions Sterilization IUD Pill Condom Average Cost/CYP US$0.50 US$0.80 US$2.3 US$4.0 US$1.52 Benefit/Cost 4.8 4.4 3.1 3.0 3.8 22. Coherence with recommended minimum package of services. The main purpose of the analysis is not to determnine a set of minimum package of services for Guinea as discussed in the 1993 WDR or the Africa Region-specific BHA; such an exercise was done in Jha, 1996. However, what follows confirms that the project objectives are comparable with the results of the above studies; thus demonstrating that the project supports the two clusters of selected interventions that are known to be highly cost effective: (a) public health interventions such as immunizations, family planning, improvements to household environment, STI/AIDS prevention, and school-based health programs and services; and (b) selected clinical services such as pregnancy related care, family planning and STI/AIDS prevention and control. Project Appraisal Document Project Title: Population and Reproductive Health Country: Guinea Annex 4: Page 8 of 10 23. Measurement of difficulties and of other benefits. Potential benefits from the population aspects of the project that would lead to a reduction in fertility and population growth in the long run are not readily measured through the computation of DALY gained. In general, specifying and estimating the measurable benefits of inter-sectoral social programs such as the proposed project is problematic. While greater information is available on the costs, benefits are multidimensional, time-bound and more difficult to quantify. Among benefits that cannot be realistically measured are the enhanced choice of women's empowerment through control of the timing and frequency of childbearing. For illustrative purposes, several attempts have been made including that of comparing the future public expenditure savings from a lower population to the costs of the family planning program. Though such exercises have resulted into internal rates of returns of 11 percent of higher in several low income countries, they suffer from a number of limitations which make the results quite controversial. Key underlying assumptions such as the rate of contraceptive acceptors and the ensuing reduction of fertility, and the limited social benefits defined in terms of public expenditure savings are difficult to substantiate and defend. X. Poverty Alleviation Impact 24. Irreversible poverty impact. Better and widespread information on population dynamics, reproductive health matters and greater contraceptive choices, together with a reduction in infant and child mortality, will gradually lead to an increase in Guinea: Population Growth & Per- the utilization of family planning services and ! ~~capitat Income (1980-2010) c improve reproductive health services. The latter will 4.0 . attract millions of rural women with "unmet 3.5 --------------- contraceptive needs" whose fertility levels are higher S 3.0 _-. ..... than desired. The recent national workshops n- 5. ... .--conducted during the project preparation suggest that *.// 2.0 -around 80 percent of women of reproductive age (1.8 " - - /// - j million) may be in this category. In addition to direct l 15 /// all benefits to current service users, there will be an 0 1-0 ....... ------ ---- inter-generational effect as existing children receive 0.5 ----- ...... ........ higher levels of investment in the development of 0.0 their human capital that will prepare them to face the 1989-90 . 1990-00 2000-05 - 2001 i10 ! -0.5 - challenges of the twenty first century. Finally, Thirty-Year Period Starting from 1980 economic and environmental benefits will accrue to 7-__OptimisticScenaro i society as a whole from a reduced and manageable __PBusinessicCase Usu population growth. The above graph clearly illustrates the value-added of such an outcome in terms of growth in per-capita income over the next 10-15 years. XI. Sensitivity Analysis Linked to Major Risk Factors 25. Political stability and ownership of the project. Apart from the failed military putsch of February 1996, Guinea has enjoyed a politically stable environment that had created the required business confidence for economic and social development. Nevertheless, the 1996 event was a bitter reminder that political instability cannot be ignored. On the borrower's commitment and ownership, there are strong indications (see Block 2, para. 11) that the process has been made irreversible regardless of future political events: steps are being taken to remove legal barriers prohibiting the sale and advertisement of contraceptives; and official population and reproductive health policies have been prepared and endorsed Project Appraisal Document Project Title: Population and Reproductive Health Country: Guinea Annex 4: Page 9 of 10 by the Government. Moreover, the participatory approach promoted by the project to make communities participate more actively in their livelihood and well-being makes any backtracking or policy reversal rather unlikely. 26. Pervasive practices to slowdown population and family planning activities. "Social habit is a second nature" and so are cultural and religious practices that do not always support active population and family planning. Segments of the targeted audiences (the youth in particular) might be more influenced by highly visible volunteers from extremist groups with different views. Though the irreversibility of the process would not be called into question, these counter-events might dilute the effort, slowdown the pace of implementation, and undermine actual results on the ground. 27. Adverse economic downturn. Despite the recent diversification effort, the Guinean economy remains vulnerable to external terms of trade shocks which, in turn, have an adverse effect on budgetary revenues. Though project design has often taken the blame for slow pace of implementation, a deeper analysis shows that lack of counterpart funds is highly correlated to project execution and performance. So long as the country's engine of growth and foreign exchange source remain mostly bauxite and other minerals, the potentially severe external market risks cannot be discounted. 28. Inadequate donor support. Given its weak absorptive and institutional capacities, Guinea is a typical case where donor coordination and support is critical to project outcomes. Though the proposed project does not embrace a sector-wide approach, it relies quite heavily on complementary programs and funding from other partners such as UNICEF, USAID, UNFPA, and more importantly numerous local and international NGOs for its implementation. The potential risk in that regard could be the added confusion partners may create by pushing their pet projects to the detriment of ownership and stakeholder participation. As indicated earlier, every effort has been made to reduce such a risk. XII. Environment Assessment 29. Beneficial long term impact. This is a category C rated project with no negative environmental impact. On quite the contrary, its downward pressure on population growth will likely have lasting positive effects on the environment in the long run by slowing down the rapid rates of both deforestation for agricultural needs and urbanization. In the short-term, major environmentally-friendly activities such as basic hygiene and sanitation will be promoted by health district teams, local partners and community awareness. Schools and in-service programs will include training of clinical staff in proper handling and disposing of blood products and other contaminants such as needles and hazardous materials. Through grassroots IEC initiatives, communities will be mobilized to improve the environment for better health (1993 WDR, Chapter 2, pages 37-51). Project Appraisal Document Project Title: Population and Reproductive Health Country: Guinea Annex 4: Page 10 of 10 Appendix I Page I of I 1-June -98 Guinea: Population and Reproductive Health Project Cost-Effectiveness Analysis of Broad Categories of Health Inte,ventions Target Groups and Beneficiaries C-E 0-4 years 5-9 years 10-24 years M W RA Others ALL Indicator NATURE OF INTERVENTIONS A. Communications for Behavior Changes in Reproductive Health (BCC/R.H.) - Information on Pop/RH by trained communicators I&4 HCE - Information with small medias on Reprod. Health X X I&4 HCE - Information via mass medias on Reprod. Health X X 2&4 HCE - Education on FP by trained group leaders X X 2,3&5 HCE - Counseling on FP by trained group leaders X X 2&5 HCE - Education on STI/AIDS by trained group leaders X X 2,3&4 HCE - Counseling on STIIAIDS by trained group leaders X X 2&5 HCE B. Reproductive Health Service - Counseling on FP by trained providers _ X X X 2&3 HCE - Improved use of FP services in health centers X 2&5 HCE - Outreach on FP by trained distributors X X 1,2&5 CE - Early treatment of STI by health providers X X 2&3 CE - Childhood cluster (pertussis, polio, measles, tetanus) X _ 2&3 HCE - Integrated case management of childhood illnesses X _ _ 2&3 HCE -Perinata and materal causes X __ WRA 2&3 HCE - Access to RH care by 75% OF Guinean population MWRA NA C. Population & Community Participation Involvement of NGOs in community organization ALL NA - Involvement of NGOs in programs implementation _ ALL NA - Reinforcing Safe Motherhood at community level W RA HCE - Reinforcing Early Childhood Programs X HCE - Reinforcing Nutrition/Feeding Programs X X W RA HCE - Cost Sharing and financial autonomy of health centers ALL NA D. Institutional Devt. & Support for Services - Provision of accurate and timely information ALL NA - Improve resources allocation ALL NA - Improve financial resources mobilization ALL NA - Decentralized preparation of annual WrkPL & Budgets ALL NA - Decentralized implementation of RH programs ALL NA - Strenghten logistics of Eds and contraceptives ALL NA - Strengten training and supervisory programs _ ALL NA - Availability of trained and supervisory personnel ALL NA - Quality of Reproductive Health Care at all levels ALL NA E. Other Interventions not classified elsewhere C-E= Cost Effective HCE= Highly Cost Effective NA: Not Applicable Project Appraisal Document Project Title: Population and Reproductive Health Country: Guinea Annex 5: Page I of I Annex 5: Financial Summary Years Ending December 31 (million US$) Phase I Phase II 1999 2000 2001 2002 2003 2004 2005 2006 Project Costs - Investment Costs 1.41 3.59 2.32 2.26 3.59 3.05 2.85 2.51 - Recurrent Costs 0.75 0.53 0.54 0.60 0.90 0.90 1.10 1.10 Total 2.16 4.12 2.86 2.86 4.49 3.95 3.95 3.61 Financing Sources (% of total project costs) - IBRD/IDA 93% 96% 94% 94% 80% 90% 87% 80% - Co-financiers 7% 4% 5% 5% 4% 8% 9% 10% -Government 0% 1% 1% 1% 16% 3% 4% 10% Total 100% 100% 100% 100% 100% 100% 100% 100% Project Appraisal Document Project Title: Population and Reproductive Health Country: Guinea Annex 6: Page 1 of 8 Annex 6: Procurement and Disbursement Arrangements Procurement No special exceptions, permits, or licenses need to be specified in the Credit documents for International Competitive Bidding (ICB), since Guinea's procurement practices allow IDA procedures to take precedence over any contrary provisions in local regulations. Procurement of works, goods and consultant services financed by the IDA credit will be carried out in accordance with the Guidelines: Procurement under IBRD Loans and IDA Credits (January 1995, revised in January and August 1996 and September 1997) and Guidelines for the Selection of Consultants by the World Bank Borrowers published in January 1997. National Competitive Bidding (NCB) advertised locally would be carried out in accordance with Guinea's procurement laws and regulations, acceptable to IDA provided that: (i) any bidder is given sufficient time to submit bids (four weeks); (ii) bid evaluation and bidder qualification are clearly specified in bidding documents; (iii) no preference margin is granted to domestic contractors and manufacturers; (iv) no eligible firms precluded from participation, regardless of nationality; (v) contracts will be awarded to the lowest evaluated bidder; and (vi) prior to issuing the first call for bids, draft standard bidding documents are submitted to IDA and found acceptable. IDA's Standard Bidding Documents (SBD) will be used for all ICB procurements. Bidding documents agreed upon by IDA and used for National Competitive Bidding (NCB) in the Health and Nutrition Project (PSN) will be used for National Competitive Bidding (NCB) procurements under the program. The Bank's Standard Request for Proposal (SRFP) forms will also be used for the procurement of consultant services. One ICB contract document and one NCB document for procurement of civil works and goods have been reviewed and approved by IDA during appraisal and will be confirmed during negotiations. As part of the Project Implementation Manual, the MS is preparing a draft procurement/disbursement plan; it will be reviewed by, and agreed with, IDA during negotiations. Procurement plans will be reviewed and updated at least one month prior to the start of each project year.. Civil Works' total cost is estimated at US$ 1.90 million for the whole four project years. Civil works contracts financed by IDA, estimated to cost US$ 1.81 million are for the construction and rehabilitation of health care and services facilities and other infrastructures, including women centers, youth service and population resource centers, in the regions and in Conakry. They are estimated to cost less than US$ 200,000 per contract, up to an aggregate amount of US$ 0.95 million, and would be procured through NCB procedures. Contracts for small works estimated to cost less than US$50,000 per contract, up to an aggregate amount of US$ 950,000, may be procured under lump-sum, fixed price contracts awarded on the basis of quotations obtained from three qualified domestic contractors invited in writing to bid. The invitation shall include a detailed description of the works, including basic specifications, the required completion date, a basic form of agreement acceptable to IDA, and relevant drawings where applicable. The awards would be made to the contractors who offer the lowest price quotation for the required work, provided they demonstrate they have the experience and resources to complete the contract successfully. These contracts would mostly be for works relating to small constructions such as health posts and replacement or rehabilitation of existing facilities in rural areas. Goods' total cost is estimated at US$ 3.2 million, of which US$ 3.1 million will be financed by IDA, this includes health equipment kits, hospital furniture, equipment and supplies, training and audio-visual equipment and supplies, warehouse stacking and operational equipment, transport vehicles, pharmaceuticals, laboratory reagents and medical supplies, as well as office furniture, equipment and consumable. Procurement will be bulked where feasible into packages valued at US$ 100,000 or more and will be procured through ICB. Procurement of drugs valued at US$ 100,000 or more may be made through LIB, up to an aggregate total of US$ 0.75 million, from non-governmental organizations which Project Appraisal Document Project Title: Population and Reproductive Health Country: Guinea Annex 6: Page 2 of 8 specialize in drugs supply, can ensure the quality of drugs at all levels of the supply cycle, and have due authorization from primary drugs manufacturers to supply their products. This procedure implemented in comparable countries in the sub-region (Mauritania for instance) has proved to be cost effective and ensured quality. The Government would otherwise have to rely either on a firm to carry out the required testing or to make available costly equipment and highly qualified staff in the country. Procurement of office furniture, vehicles and fuel valued at less than US$ 100,000 up to an aggregate total of US$ 0.22 million will be procured through NCB. Implementation of the program would require the purchase of relatively small, mainly consumable items, by MS local offices, regional authorities and communities around the country, which would be difficult and impractical to package and procure following NCB procedures. Thus, such items (mostly pharmaceuticals, contraceptives, medical equipment, vehicle, furniture and office equipment) which could not be grouped into ICB packages and costing less than US$ 100,000 per contract, up to an aggregate amount not to exceed US$ 360,000, would be procured through the UNICEF Procurement and Assembly Center (UNIPAC) and/or through the Inter-Agency Procurement Services of the UNDP (IAPSO) and/or UNFPA; this would be the most economical and efficient way of procuring small quantities, in particular in case of emergency. Procurement of small equipment, furniture and vehicles spare parts costing less than US$ 20,000 equivalent per contract up to an aggregate of US$ 220,000 may be procured through prudent national shopping (for items available locally) up to US$ 120,000, or up to US$ 100,000 through international shopping (for those goods not available on the national market) on the basis of quotations obtained from at least three qualified suppliers. Spare parts, operating expenditures, minor off-the-shelf items, pharmaceuticals and other proprietary items costing less than US$ 5,000 equivalent per contract up to an aggregate of US 50,000 equivalent, may be procured directly from manufacturers and authorized local distributors. Population Support Fund (PSF) The PSF (US$0.78million) will finance activities, operations and micro-projects that meet the criteria established in a Procedural Manual. The PSF aims at supporting demand -driven activities, projects solicited by beneficiairies that have demonstrated their commitment to objectives supported by the PSF. Beneficiaries will be selected among youth or women's groups, associations, communities, cooperatives and indigenous NGOs. In general, the PSF will finance activities in the domains of IEC and safer practices; promotion of family planning and safe motherhood, training and institutional support and promotion of women's status. The PSF will be managed by an Executive Selection Committee (ESC) with equal representation from public and private social sectors and the Government. Applications and proposals will be evaluated for technical content and eligibility criteria specified in the PSF procedural manual and presented to the ESC for approval. The first four requests for PSF financing would be sent to IDA for prior review. It is expected that financial support will average about US$5,000, with a maximum of US$ 15,000 per grant. Contracts from the Fund will be managed by the PSF/NGO specialist at the "Bureau de Coordination Population et Sante ". Consultants', Training and IEC Services financed by IDA would be for: (I) studies, preparation of bidding documents, works supervision, data collection, design and operation of accounting systems, audits and impact analysis; (ii) short term consultancies for specific technical matters such as planning, contractual services and training courses design; (iii) training, locally and overseas, of health personnel staff, and (iv) behavioral change communication related services including the design, production and distribution/broadcasting of messages and information campaigns and sessions. Consultants financed by IDA, totaling US$ 3.1 million, would be hired in accordance with the Bank's Guidelines for Selection and Employment of Consultants by World Bank Borrowers dated January, 1997 and revised in September 1997. It will be addressed through competition among qualified short-listed firms in which the selection will be based on Quality-and Cost-Based Selection (QCBS) by evaluating the quality of the proposal before comparing the cost of the services to be provided. For audits and architectural and engineering services of a standard nature the Least-Cost Selection (i) will be the most appropriate Project Appraisal Document Project Title: Population and Reproductive Health Country: Guinea Annex 6: Page 3 of 8 method -- the firm with the lowest price will be selected, provided its technical proposal received the minimum mark required. Consultants services for assistance on drug procurement and logistics services, for revision and design of training curricula and modules, and for the design, testing and production/edition of messages on small and mass media (estimated at less than US$100,000 per contract up to an aggregate of US$ 250,000) would be based on Consultants' Qualifications (CQ), taking into account the consultants' experience and competence relevant to the assignment. Single Source Selection (SSS) will be exceptionally used for the management of the initial training of trainers (TOT), the broadcasting of messages through national (TV and Radio) and regional mass media (Radios rurales) and the performance of the Demographic and Health Survey (1998 DHS). Services for short-term or ad hoc consultancies, lectures and small studies which can be delivered by Individual Consultants will be selected through comparison of qualifications against job description requirements among those expressing interest in the assignment or those approached directly. For training abroad and in-country, the program -- containing names of candidates, cost estimates, content of the courses, periods of training, institution selection -- would be reviewed by IDA annually. To ensure that priority is given to the identification of suitable and qualified national individual consultants, short-lists for contracts estimated under US$ 100,000 may be comprised entirely of national consultants if a sufficient number of qualified firms (at least three) are available at competitive costs. However, if foreign firms have expressed interest, they will not be excluded from consideration. The Standard Request for Proposal (SRFP) forms as developed by the Bank will be used for the appointment of consultants. Simplified contracts will be used for short-term assignments, simple missions of standard nature i.e. those not exceeding six months, carried out by individual consultants or firms. The Government will be briefed during negotiations about the special features of the new guidelines, in particular with regards to advertisement and public bid opening. IDA Review. All contracts for construction of civil works and purchase of goods above the threshold value of US$ 100,000 will be subject to IDA's prior review procedures. The use of IDA's SBD would expedite considerably the prior review process as IDA review would primarily focus on invitation to bid, bid data sheet, contract data, technical specifications, bill of quantities/schedule of requirements and other contract-specific items. The review process would cover about 65 percent of the total value of the amount contracted for goods and about 40 percent of the amount contracted for civil works. Selective post-review of contracts awarded below the threshold levels will apply to about one in three contracts. Draft standard bidding documents for NCB will be reviewed by and agreed upon with IDA during negotiations. For consultant services, prior review will include the review of budgets, short-lists, selection procedures, letters of invitation, proposals, evaluation reports and draft contracts. Prior IDA review will not apply to contracts for the recruitment of consulting firms and individuals estimated to cost less than US$ 100,000 and US$ 50,000 equivalent respectively. However, the exception to prior IDA review will not apply to the Terms of Reference of such contracts, regardless of value, to single- source hiring, to assignments of a critical nature as determined by IDA or to amendments of contracts raising the contract value above the prior review threshold. For consultant contracts estimated above US$ 200,000, opening the financial envelopes will not take place prior to receiving the Bank's no- objection to the technical evaluation. For contracts estimated to cost less than US$ 200,000 and more than US$ 100,000 the borrower will notify IDA of the results of the technical evaluation prior to opening the financial proposals. Documents related to procurement below the prior review thresholds will be maintained by the borrower for ex-post review by auditors and by IDA supervision missions. The MS/BCPS will be required to maintain all relevant procurement documentation for subsequent review by IDA. The MS/BCPS will submit to IDA periodic procurement schedules detailing each procurement in progress and completed as part of the normal project reporting exercise. Project Appraisal Document Project Title: Population and Reproductive Health Country: Guinea Annex 6: Page 4 of 8 Procurement under the program will be handled by the Direction des Infrastructures, de l 'Equipemnt et de la Maintenance (DIEM) existing in the MS, which will assist the BCPS, using skills and competencies built under the on-going project (PSN), with the support of short-term consultants as needed. The design and supervision of all civil works (construction and rehabilitation) financed by the IDA credit will be carried out by consulting firms. This arrangement will be the same as for the current project (PSN) which proved to be suitable for even a much larger infrastructure component. The decentralized directorates of the MS will be responsible for the overall activity planning in the regions, the identification and availability of land (if required), the preparation of equipment lists and any other information needed by DIEM to prepare bidding documents for the procurement of goods, or terms of reference for the selection of consultants as well as the evaluation of their perforrnance from the technical point of view. All technical specifications for medical equipment are currently being prepared by a specialized consulting firm and will be submitted to IDA for review before negotiations. Information related to civil works will be transmitted by the DIEM to the firm(s) in charge of the preparation of detailed design and bidding documents for works. Also, to facilitate implementation, small and urgent procurement may be done through IAPSO and through UNIPAC or other non-governmental organizations (as long as it is the least cost solution) -- in accordance with the provisions described below for the procurement of goods. For all other procurement handled by the DIEM, the procurement methods described below and summarized in Table A will apply. Project Appraisal Document Project Title: Population and Reproductive Health Country: Guinea Annex 6: Page 5 of 8 Table A: Program Costs by Procurement Arrangements (in US$ million equivalent including taxes, duties and contingencies) Expenditure Category Procurement Method Total Cost (incl. contingencies) ICB NCB Other N.B.F 1. Works 0.96 0.95 1.91 (0.90) (0.90) (1.81) 1.1 health infrastructures - 0.53 0.60 1.13 (0.51) (0.57) (1.08) 1.2 other civil works - 0.42 0.35 - 0.7 (0.40) (0.33) (0.73) 2. Goods 1.47 0.22 1.38 0.08 3.15 (1.47) (0.22) (1.38) (3.07) 2.1 medical equipment 0.60 - 0.26 - 0.86 (0.60) (0.26) (0.86) 2.2 equipment/furniture, 0.72 0.22 0.13 0.08 1.15 vehicles (0.72) (0.22) (0.13) (1.05) 2.3 pharmaceuticals/drugs, 0.15 - 0.99 - 1.14 contraceptives (0.15) (0.99) (1.14) 3. Services 3.05 3.05 (3.05) (3.05) 3.1 CW engineer/arch, - - 0.80 - 0.80 management/computer (0.80) (0.80) consultancies and audit 3.2 Training, studies, - - 0.66 - 0.66 contractual services, (0.66) (0.66) short term consultancies 3.3 IEC/Media - - 1.60 1.60 (160) (1.60) 4. Miscellaneous 3.60 0.03 3.63 (3.38) (3.38) 4.1 operating costs - - 2.22 0.03 2.25 (2.00) (2.00) 4.2 PSF Grants - - 0.78 0.78 (0.78) (0.78) 4.3 PPF refinancing - - 0.60 - 0.60 (0.60) (0.60) Total Costs 1.47 1.17 8.98 11.73 Total Financed by IDA (1.47) (1.12) (8.71) 0.11 (11.30) Note: NBF = Not Bank-financed. Figures in parenthesis are the amounts to be financed by the Bank loan/IDA credit. Total may not add up due to rounding. Project Appraisal Document Project Title: Population and Reproductive Health Country: Guinea Annex 6: Page 6 of 8 Table B: Thresholds for Procurement Methods and Prior Review Expenditure Contract Value Procurement Contracts Subject to Category (Threshold) Methods Prior Review * 1ef 5 ' ',§e,,,,; . ¢ ; ________________________'____ I CB NCB Other above US$200,000 X Prior IDA review above US$100,000 X Prior IDA review below US$100,000 X X Post review . Aggregate above US$50,000 amount: US$350,000 below US$50,000 X Post review . Aggregate _______________________ _______ _______ ____________ amount: US$950,000 above US$100,000 X Prior IDA review above US$100,000 LIB for Prior IDA review procurement Aggregate amount: of drugs US$750,000 below US$100,000 X Post review . Aggregate above US$20,000 amount: US$220,000 below US$100,000 IAPSO or Post review. Contraceptives and UNIPAC Aggregate amount: Medical equipment US$360,000 below US$20,000 X Post review aggregate amount for shopping: National: US$120,000 L______________________ _______ ______ ____________ International: US$100,000 below US$5,000 direct X Post review. Aggregate purchase from amount: US$50,000 manufacturers or authorized dealers i3. itService0-0.CNj77s7 77 77 Selection Methods All TORs or sole source contracts are subject to IDA prior review Audit, civil works N/A Least Cost Selection Prior Review design/supervision Firms Above US$200,000 Quality and Cost Based -Prior Review + Review of Selection (QCBS) Technical Evaluation Report Drugs logistics, Above US$100,000 before opening financial Design training Below US$200,000 proposal curricula, Consultants' Qualifications -Prior Review + (i) Media/IEC Below US$100,000. (CQ) notification of Technical Evaluation scores, (ii) combined evaluation report Consultants' Qualifications CQ Post Review TOT, Media, DHS N/A Single Source Selection Prior Review N/A Single Source Selection Prior Review Individuals Above US$50,000 Section V of Consultants Prior Review Below US$50,000 Guidelines Post Review Project Appraisal Document Project Title: Population and Reproductive Health Country: Guinea Annex 6: Page 7 of 8 Conditions for negotiations are mentioned in PAD - section G. During negotiations, agreement will be reached on the proper monitoring of procurement, as well as the standard procurement documents to be used for NCB. The Government will give assurance at negotiations that it will: (a) use the Program Implementation Manual for Project Implementation; (b) use the Bank's Standard Bidding Documents for ICB; (c) apply the procurement procedures and arrangements outlined in the above documents; and (d) review the procurement plan and procurement arrangements each year (immediately after the annual review with IDA and before the beginning of the next fiscal year). During implementation, all bidding documents, bid evaluation reports, and draft contracts transmitted to IDA for review will contain an updated copy of the procurement planning. Procurement information will be collected and recorded as follows: (a) prompt recording of contract award information by the Borrower; and (b) semi-annual reports to the Bank by the Borrower indicating: (i) revised cost estimates for individual contracts and the total program, including best estimates of allowances for contingencies; (ii) revised timing of estimated procurement actions, including experience with completion time and completion cost for individual contracts; and (iii) compliance with aggregate limits on specified methods of procurement. A detailed procurement plan for works, goods and services to be procured under the project was prepared and will be agreed during negotiations. It will be updated and reviewed on a regular basis during annual reviews. The Government will give assurance at negotiations that it will take the necessary measures to ensure that procurement phases do not exceed the following target time periods: Maximum number of weeks * Preparation of bidding documents 4 (12 for large contracts) * Preparation of bids by bidders 4 (6 for ICB) * Bid evaluation 2 (4 for large contracts) * Signature of contracts 2 * Payments 4 Disbursement The proposed allocation of the credit is shown in Table C. The IDA credit will be disbursed over a period of five years (from 1998 to 2003), with a closing date of June 30, 2003. The estimated disbursement schedule is shown in Table D. All applications to withdraw proceeds from the credit will be fully documented, except for contracts not subject to prior review by IDA. For the rest, disbursements will be made against Statements of Expenditures (SOEs) certified by the head of the BCPS/MS. Supporting documentation will be retained by BCPS/MS and will be available for review as requested by IDA supervision missions and program auditors. Project Appraisal Document Project Title: Population and Reproductive Health Country: Guinea Annex 6: Page 8 of 8 Table C: Allocation of Credit Proceeds Expenditure Category Amount in US$ Amounts in Financing million SDR Percentage 1. Works 1.70 1.30 95% 2. Goods (including medical equipment, 2.90 2.20 100% of foreign drugs, reagents, office equipment, vehicles, and 95% of and furniture) local expenditures 3. Services (including long term TA, short 2.88 2.10 100% term consultancy, civil works contract management and training) 4. PSF Matching Grants 0.74. 0.50 100% of amounts ________________________________________ disbursed 5. Operating Costsl/ 1.88 1.40 90% 6. Refunding of PPF Advance 0.60 0.50 7. Unallocated 0.60 0.50 Total IDA credit 11.30 8.50 1/ Operating costs include incremental operating costs incurred on account of program implementation, management and supervision, including office supplies, office equipment and vehicles operation and maintenance, contractual services and travel and allowances including those for trainers and trainees, but excluding salaries of officials of the borrower's civil service. Table D: Estimated Disbursements of IDA Credit (US$ million) IDA 1999 2000 2001 2002 2003 Fiscal Year Annual 1.00 3.00 3.50 2.30 1.50 Cumulative 1.00 4.00 7.50 9.80 11.30 Cumulative 11% 35% 66% 88% 1 00% A Special Account will be opened for the IDA credit and maintained with a commercial bank, acceptable to IDA. The maximum balance in the Special Account will be US$750,000, which will cover about 4 months of expenditures, to be disbursed from the Special Account. Project Appraisal Document Project Title: Population and Reproductive Health Country: Guinea Annex 7: Page I of I Annex 7: Project Processing Budget and Schedule A. Project Budget (US$000) Planned Actual (At final PCD stage) B. Project Schedule Planned Actual (At final PCD stage) 121,000 98,000 Time taken to prepare the project (months) 10 months First Bank mission (identification) 06/15/97 06/15/97 Appraisal mission departure 11/10/97 02/09/98 Negotiations 03/07/98 06/16/98 Planned Date of Effectiveness 12/24/98 12/24/98 Prepared by: Ministry of Health of Guinea Preparation assistance: 1) Japanese Grant: $400,000 2) PPF: $600,000 Bank staff who worked on the project included: M. Dia Country Director D. Webber Sr.Financial Mgmt. Spec. 0. Jah Operations Analyst L. Strengerowski- Disbursement Analyst Feldblyum B. Herz, Adviser G.Tschannerl Principal Operations Officer Mpoy-Kamulayi, Sr. Counsel 0. Pannenborg Lead Specialist S. Boubacar Sr. Counsel C. Walker. Lead Specialist F. Agueh, Operations Manager S. Ben-Halima Task Team Leader N. Burnett Sector Manager W. Ravaonoromalala Consultant H. Burmeister Sr. Projects Officer Cherif Diallo Consultant R. Crowne Projects Officer J. May Consultant J. Harrington, Sr. Population Specialist D. Diarra-Kambou Consultant B. Abeille Sr. Procurment Specialist H. Afsar Administrative Asst. E. Jarawan Sr. Health Specialist A. Kamau Task Team Assistant A. Tinker Principal Health Specialist S. V. Nakhavanit Task Team Assistant S. Luculescu Principal Health Specialist E. Locatelli Field Coordinator Project Appraisal Document Project Title: Population and Reproductive Health Country: Guinea Annex 8: Page I of 3 Annex 8: Documents in the Project Files* A. Documents related to Project Implementation Plan 1. Population and Reproductive Health Project (reference document for implementation planning). "Evolution de la Population Guineenne par prefecture et estimation de la population desjeunes et femmes en dge de procreer, RGPH 1983 et 1996" Republic of Guinea. October 1997. 2. Population and Reproductive Health Project (Preparation phase). "Composantes, sous - composantes - activites, dchdancier de realisation" Republic of Guinea. November 1997. 3. Population and Reproductive Health Project (Preparation phase). "Liste et categories des infrastructures a construire, a rehabiliter et a renover selon le nombre total d' habitants" Republic of Guinea. November 1997. 4. Analyse dconomique du projet par Goudoussy Balde, Novembre 1997. 5. "Manuel de procedures de gestion " par Mohamed Sano, Avril 1998. B. Bank Staff Assessments Better Health of Africa 1994 World Bank Development Report "Investing in Health"1998. World Bank missions * * Poverty assessment in Guinea 1. Pre-identification: "Document technique de reference pour la phase de prdparation" March 1997. 2. Participatory Project Identification and Planning :"Rapport des ateliers de planifi cation ZOPP", June 1997. 3. Forecasting contraceptive commodities and recommendations for Logistic systems, September 1997. 4. Pre-appraisal document: "Document de travail pour la description detaillee du projet", October 1997. 5. Comments on economic analysis, informations to be collected by the local consultant, December 1997. External agencies 1. USAID/GUINEA HEALTH PROJECT/MOH, Guinea Pharmaceutical Sector Assessment (draft), May 1995. Project Appraisal Document Project Title: Population and Reproductive Health Country: Guinea Annex 8: Page 2 of 3 2. PSI-GUINEE, PROJET FAMPOP: "Bilan Statistique (1992-1995) ", December 1995. 3. PSI-GUINEE, Evaluation of Guinea Family Planning Options Project (FAMPOP), February 1996. 4. UNICEF-GUINEA, "Plan d'Operations Sectoriel, 1997-2001 " July 1996. 5. GTZ, in collaboration with UNICEF-GUINEA: "Evaluation du system de participation communautaire du Programme PEV/SSP/ME, Rapport Final" September 1996. 6. ASSOCIATION GUINEENNE POUR LE BIEN-ETRE FAMILIAL (AGBEF): "Plan Triennal 1997- 1999 " 7. UNFPA-GUINEA, "Sous-programme: Sante de la Reproduction/Planification Familiale" March 1997. 8. USAID, The Evaluation Project: Handbook of Indicators for Family Planning Evaluation. 9. Columbia University in the City of New York, CPFH: The Design and Evaluation of Maternal Mortality Programs. C. Other 1. Reports of consultative workshops conducted during Project preparation , June - September 1997. 1.1. Lamarana Diallo: "Rapports des 21 ateliers consultatifs regionaux ex&cutks par l 'AGBEF' 1.2. Bandian Sidime and Munze Mey Atu: "Rapport de Synthese des Ateliers Consultatifs Regionaux " 2. Executive summaries of base line studies for the Population and Reproductive Health Project: 2.1. Fode Bangaly Keita: "Obstacles a l'acceptation des methodes modernes de Planning Familial ". 2.2. Boubacar Sylla and Daniel Tolno: "Connaissances, Attitudes et Pratiques des jeunes Guineens en Sante de la Reproduction ". 2.3. Malick Kouyate: "Connaissances, Attitudes et Pratiques en Planning Familial des leaders d'opinion et d&cideurs Guineens ". 2.4. Ibrahim Bah-Lalya: "Evaluation des programmes d' Education non formelle pour integrer la Santk de la Reproduction ". Project Appraisal Document Project Title: Population and Reproductive Health Country: Guinea Annex 8: Page 3 of 3 2.5. Bouba Toure: "Etude narrative de la Mortalite Maternelle en Guinee, propositions pour la prevention ". 2.6. Mohamed Sano: "Etude narrative sur les MST/VIH/SIDA en Guinie, propositions pour la prevention ". 2.7. Saran Toure: "Personnes-relais, associations et medias: mrthodes et strategie de communication ". 2.8. Laurent Kamano: "Etude retrospective du Cadre Institutionnel de la Politique et Programme de Population". 2.9. Diallo Fofana Fatoumata and Hyjazi Yolande: " Revue de la literature en Santi de la reproduction en Guinee " 3 . Morissanda Kouyate, CPTAFE: "Plan d'Action 1998-2002, Dec. 1997 D. Key documents by Government of Guinea 1. "Declaration de Politique de Population, Version revisee, Septembre 1996". 2. "Programme National de Population, programme prioritaire 1997-2001 " 3. "Forum National de la Sante: Analyse de la situation, perspectives, Mai 1997" 4. "Nornes et procedures de la Sante de la Reproduction, Draft, Fevrier 1997" 5. "Sante de la Reproduction, Strategie IEC, Juin 1996" *Including electronic files. Project Appraisal Report Project Title: Population and Reproductive Health Country: Guinea Annex 9: Page 1 of 2 Annex 9: Statement of Loans and Credits Status of Bank Group Operations in Guinea IBRD Loans and IDA Credits in the Operations Portfolio Difference Between expected Original Amount in US$ Millions and actual Last ARPP Loan or Fiscal disbursements a/ Supervision Rating b/ Project ID Credit Year Borrower Purpose No. IBRD IDA Cancellations Undisbursed Orig Frm Rev'd Dev Obj Imp Prog Number of Closed Loans/credits: 43 Active Loans GN-PE-1059 IDA 21120 1990 GOVT OF GUINEA SECOND URBAN 0.00 57.00 0.00 4.08 .60 0.00 S S GN-PE-1043 IDA 24160 1993 GOVERNMENT OF GUINEA POWER II 0.00 50.00 0.00 5.00 3.65 3.65 U U GN-PE-1068 IDA 24070 1993 GOVT OF GUINEA AGR.EXPORT PROMOTION 0.00 20.80 0.00 12.07 8.43 0.00 S S GN-PE-1070 IDA 25740 1994 GOVERNMENT HEALTH/NUT.SCTR. 0.00 24.60 0.00 14.70 3.00 2.70 S S GN-PE-1087 IDA 27190 1995 GOVERNMENT EQUITY AND SCHOOL IM 0.00 42.50 0.00 28.53 12.60 0.00 HS S GN-PE-1078 IDA 26530 1995 GOVERNMENT FINANCIAL SECTOR 0.00 23.00 0.00 1.56 1.02 0.00 S S GN-PE-1077 IDA 28740 1996 GOVERNMENT MIN SECT INV PROMOT 0.00 12.20 0.00 7.74 3.19 0.00 S S GN-PE-1081 IDA 28390 1996 GOVERNMENT AGRIC SERVICES 0.00 35.00 0.00 22.57 .98 0.00 S S GN-PE-1090 IDA 27870 1996 GOVERNMENT HIGHER EDUCATION MAN 0.00 6.60 0.00 4.82 2.99 2.28 U U GN-PE-1075 IDA N0170 1997 GOVERNMENT THIRD WATER SUPPLY 0.00 25.00 0.00 23.98 .79 0.00 S S GN-PE-49690 IDA 30210 1998 GOVERNMENT PUB.EXP.MNG.ADJ.CRD 0.00 70.00 0.00 24.40 3.09 0.00 S S Total 0.00 366.70 0.00 149.45 40.34 8.63 Active Loans Closed Loans Total Total Disbursed (IBRD and IDA): 211.85 810.18 1,022.03 of which has been repaid: 0.00 92.03 92.03 Total now held by IBRD and IDA: 366.70 671.82 1,038.52 Amount sold : 0.00 0.00 0.00 Of which repaid : 0.00 0.00 0.00 Total Undisbursed : 149.45 .14 149.59 a. Intended disbursements to date minus actual disbursements to date as projected at appraisal. b. Following the FY94 Annual Review of Portfolio performance (ARPP), a letter based system was introduced (HS = highly Satisfactory, S = satisfactory, U 5 unsatisfactory, HU = highly unsatisfactory): see proposed Improvements in Project and Portfolio Performance Rating Methodology (SecM94-901), August 23, 1994. Note: Disbursement data is updated at the end of the first week of the month. Project Appraisal Report Project Title: Population and Reproductive Health Country: Guinea Annex 9: Page 2 of 2 ANNEX 9: STATEMENT OF IFC's Committed and Disbursed Portfolio As of 30-Apr-98 (In US Dollars Million) Committed Disbursed IFC IFC FY Approval Company Loan Equity Quasi Partic Loan Equity Quasi Partic 1988 Aurifere 0.00 0.00 4.59 0.00 0.00 0.00 4.59 0.00 1993 SGHI 2.77 .56 .21 0.00 2.77 .56 .21 0.00 1994 Ciments .79 0.00 0.00 0.00 .79 0.00 0.00 0.00 Guinee 1998 SEF Agro .20 0.00 0.00 0.00 .20 0.00 0.00 0.00 Total Portfolio: 3.76 .56 4.80 0.00 3.76 .56 4.80 0.00 Approvals Pending Commitment Loan Equity Quasi Partic Total Pending Commitment: 0.00 .00 0.00 0.00 Project Appraisal Document Project Title: Population and Reproductive Health Country: Guinea Annex 10: Page 1 of 2 Guinea at a glance 8119197 Sub- POVERTY and SOCIAL Saharan Low- Guinea Africa Income Development diamond' Populabon mid-1996 (millions) 6.8 600 3,229 GNP per capita 1996 (US$) 560 490 500Lfe expectancy GNP 1996 (biions US$) 3.8 294 1,601 Average annual growth, 1990-96 Populaion (°Ai) 2.7 2.7 1.7 1 GNP Gross Labor force (Y.) 2.4 2.6 1.7 Gross per primary Most recent estimate (latest year available since 1989) rcapita enrollment Poverty: headcount index (% of population) .. Urban population (% oftotalpopulation) 30 31 29 Life expectancy at birth (years) 44 52 63 Infant mortality (per 1,000 live births) 128 92 69 Access to safe water Child malnutrition (°XO of children under 5) 18 Access to safe water (% of population) 49 47 53 Illiteracy (% of population age 15+) 76 43 34 Guinea Gross primary enrollment (% ofschool-age population) 50 72 105 Male 59 78 112 Low4ncome group Female 33 65 98 1 KEY ECONOMIC RATIOS and LONG-TERM TRENDS 1975 1985 1995 1996 Economic ratlos* GOP (billons US$) .. .. 3.7 4.0 1 Gross domestic investment/GDP . .. 14.5 13.0 i Openness of economy Exports of goods and services/GDP .. .. 21.7 18.9 i Gross domestic savings/GDP .. .. 10.1 10.0 Gross national savings/GOP .. .. 6.2 5.4 Current account balance/GOP .. .. -8.2 -7.6 . Interest payments/GDP .. .. 1.1 1.6 Savings Investment Total debtWGDP .. .. 87.2 73.0 Total debt service/exports .. .. 22.4 32.1 Present value of debt/GDP .. .. 56.6 Present value of debt/exports .. .. 260.1 Indebtedness i975-85 1986-96 1995 1996 1997405 : (average annual growth) - Guinea GOP .. 4.0 4.4 4.5 5.0 __ GNP per capita 1.8 1.3 1.3 5605 Low-income group Exports of goods and services .. 3.0 11.3 -3.2 7.6 i STRUCTURE of the ECONOMY 1975 1988 1995 1996 i (X of GDP) i Growth rates of output and investment (%) Agriculture .. .. 24.5 24.7 - 'o Industry .. .. 34.0 33.9 ___ Manufacturing .. .. 4.7 * 4.6 ! j\ Services 41.5 41.4 1'o rT Prvate consumption .. .. 81.5 81.9 .20 ' General govemment consumption .. .. 8.4 8.1 |GDI I+ GDP Imports of goods and services .. .. 26.1 21.9 ! 1975-85 1986-96 1996 1996 (average annual growth) Growth rates of exports and Imports (%) Agnculture .. 4.2 3.5 5.0 is Industry , 2.6 3.7 4.3 sA Manufacturing .. 4.1 3.1 3.0 Services .. 4.7 5.2 3.8 A AA Private consumption . 3.8 1.7 5.2 s1 93 96 General govemment consumption .. 4.6 3.3 2.8 Gross domestic investment .. 2.1 7.4 44 .10 l Imports of goods and services .. 1.6 5.3 -8.0 Exports Im s Gross national product 4.6 4.2 4.2 Note: 1996 data are preliminary estimates. be incomplete. Project Appraisal Document Project Title: Population and Reproductive Health Country: Guinea Annex 10: Page 2 of 2 Guinea PRICES and GOVERNMENT FINANCE 1975 1985 1995 1996 I Domestic prices Infation (%) (% change) 30 - Consumer prices .. .. 5.8 5.0 ! Implicit GDP deflator .. .. 5.2 3.8 Govemment finance (% of GOP) 0 Currentrevenue .. .. 11.8 10.2 9 92 93 94 95 95 Current budget balance ,. .. 2.6 1.3 -GOP def. * ICPI Overall surplus/deficit .. .. -6.0 -6.0 TRADE 1978 1985 1995 1996 (millions USS) Export and import levels (mill. USS) Total exports (fob) .. .. 747 696 900 Other metals .. .. 299 324 9o0 Aluminum . .. 110 104 Manufactures .. .. 0 0 N Total imports (cif) .. .. 809 714 400 d Food .. 77 76 300 Fuel and-energy .. .. 82 87 2 10O Capital goods .. .. 88 78 0 Export price index (1987=100) .. .. 93 90 90 91 92 93 94 ff 96 Import price index (1987=100) .. .. 126 124 a Exports glmports Terms of trade (1987=100) .. .. 74 73 BALANCE of PAYMENTS 1975 1985 1996 1996 (millions US$) Current account balance to GOP ratio (%) Exports of goods and services .. .. 798 746 0 Imports of goods and services .. .. 960 866 Resource balance .. .. -162 -120 Net income -3 18 . Net current transfers -7 131 Current account balance, before official capital transfers .. .. -305 -300 Financing items (net) 318 273 Changes in net reserves -3 -2 -13 27 -15- Memo: Reserves including gold (mill. US$) 0 0 198 199 Conversion rate (locaL4US$) 20.3 24.3 979.6 998.4 EXTERNAL DEBT and RESOURCE FLOWS (millions US$) Composition of total debt, 1996 (mill. US$) Total debt outstanding and disbursed 774 1,466 3,242 2,887 G IBRD 68 55 0 0 , F IDA 0 117 847 863 173 Total debt service 39 72 181 242 IBRD 8 8 0 0 IDA 0 1 8 11 Composition of net resource flows . Official grants 3 4 0 3 10r24 Official creditors 54 48 70 37 C Prvate creditors * 4 18 -15 -6 as Foreign direct investment 0 1 .. 0 Portfolio equity 0 0 .. 0 i 679 World Bank program Commitments 21 33 43 54 A - IBRO E - Bilateral Disbursements 0 22 59 47 B - IDA 0 - Other multilateral F - Pnvate Principal repayments 2 s 2 4 C - IMF C - Shart-erm Netflows -2 17 57 43 1 Interest payments 6 4 6 7 Net transfers -8 12 51 36 Development Economics 8/19/97 ' Q W . ?g Ni IUdUUt Ut UUINEE Cr i lili Travail- Jus*x s.SoBd" w ; 7 VCEID 086 MARS 1998 LI 3 MINISTERE DU PLANET ET DE LA COOPERATION AFWRIC N llt 0 04 3 ...MPCICAB .....9 C7 PROJET POPULATION ET SANTE GENESIQUE r ^ Lettre de politique , Monsieur le President de la Banque Mondiale, 1818 H Street, NW Washington, D.C. 20433 Objet: Lettre de Politique de Diveloppement Refarence: Projet Population et Sante Genisique (PPSG) en R6publique de Guinee. Cher Monsieur, La Loi Fondamentale, adoptee le 23 decembre 1990, proclame l'adhesion de la Guinie aux principes, droits et devoirs etablis par la Declaration Universelle des Droits de 1'Homme et la Charte Africaine des Droits de l'Homme et des Peuples. Le droit a la sante et le devoir pour l'Etat de promouvoir le bien-etre des citoyens y sont reaffirmes. Faisant suite a la lettre de Monsieur le Ministre de la Sant6, que je vous avais transmise en juillet 1996, la presente lettre de politique de d6veloppement met en exergue les contraintes majeures rencontrees dans les domaines de la population et de la sante de la reproduction, et les strategies que le Gouvemement se propose de mettre en oeuvre pour y faire face. Ce cadre strat6gique sera utilis6 par le Gouvernement comme support a la conception et a la mise en oeuvre du Projet de Population et Sant6 Genesique propose au financement de l'IDA. Contexte et expos6 des motifs Malgre tous les atouts et avantages comparatifs que mli conferent les potentia1it6s du pays, le developpement de la Guinee se heurte a des contraintes qui font qu'elle demeure classee parmi les PMA (pays les moins avances), avec un fiible niveau de developpement humain Parmi ces contraintes, figure la croissance demographique rapide qui, par la pression qu'elle exerce sur les ressources, peut compromettre la mise en oeuvre d'un d6veloppement durable. En effet, les gains de population, s'ils peuvent etre source de progres, peuvent neanmoins constituer un fardeau, car le besoin d'amelioration des conditions de vie de la population exdgera des investissements de plus en plus lourds en me_temps que deviendra de plus en plus sensible l'impact sur la d6gradation de 1'environnement BP 221 - T(dl A -1 ;2 -6 Y F:=- - di a rQO (Thnrler'i r,,; 2. En outre, au stade actuel du developpement economique de la Guinee, avec un taux de croissance economique de 4,5% dii PM en moyenne par an - que l'on espere faire passer a 5,8% durant la p6riode 1997-2010 -- et une croissance demographique annuelle de 2,8%, le PM3 par tete ne croitrait qu'a un rythme de 1,2% par an. Or pour envisager une amelioration sigaificative du niveau de vie des populations, il faudrait que la croissance economique soit au moms le double de la croissance demographique. C'est pourquoi le Gouvernement a adopte en juin 1992 la Declaration de Politique de Population pour la Guinee (DPPG), dont le document de Politique de Developpement Sectoriel, qui en est la suite logique, a ete revis6e en septembre 1996, suite aux recommandations de la Conference du Caire de 1994 sur la Population et le Developpement (CIPD). En novembre 1991, faisant le bilan des actions entreprises depuis 1984, ann6e de la Conf6rence Nationale de la Sante, le Gouvemement a promulgu6 une nouvelle Declaration de Politique Sanitaire. Cette declaration stipulait deja que la politique sanitaire visera a ameliorer la sante de l'ensemble de la population par la reduction de la morbidit6 et de la mortalite en mettant l'accent sur les groupes vuln6rables, notamment les femmes et les enfants. nI etait aussi precise que l'objectif de cette politique etait de renforcer la disponibilite, l'accessibilite, la qualit6 et l'efficacite des services de sante et qu'il fallait envisager des mesures tendant a controler la croissance demographique, ce qui a ete confirm6 par la promulgation de la politique de population en mai 1992. En mai 1997, enfm, le Forum National de la Sante a permis d'obtenir un consensus sur l'analyse de la situation du systeme de sante, le document de politique sanitaire et les axes prioritaires d'intervention pour la periode 1998-2010. II en ressort que malgr6 les progres accomplis ces demieres ann6es, l'etat sanitaire des populations guineennes est globalement mauvais. En effet, les taux de mortalite infantile (137 pour mile), de mortalite infanto-juvnhle (232 pour mille), de mortalite maternelle (respectivement 500 et 900 pour 100.000 naissances vivantes a Conakry et en Moyenne Guinee), sont parmi les plus eleves en Afrique subsaharienne, tandis que 1'esperance de vie a la naissance est l'une des plus basse: 47 ans. La situation nutritionnelle, principalement des femmes enceintes et des enfants, pose de grands problemes se traduisant par le faible poids a la naissance, la malnutriion aigue et chronique et la carence en micronutriments. La situation epidemiologique du pays se caracterise par la predominance des maladie infectieuses et parasitaires et la persistance et/ou la resurgence de certaines endemies autrefois maitris6es, a 1'exception de l'onchocercose et de la lepre qui sont heureusement en regression. De janvier 1987 a juin 1996, 2.542 cas de SIDA out et6 enregistres. La tranche d'age la plus touchee est celle de 20 a 39 ans. Ceci traduit la r6alit6 de la menace y9ur le pays, car ce sont les adolescents et les adultes jeunes qui sont les plus concernes.K A 3. Objectifs et strategie de mise en oeuvre Le programme Considerant que ces contraintes constituent un handicap majeur au developpement de la Guinee, le Gouvemement a defni, a travers les documents de politiques sectorielles de la population et de la sante, les objectifs qui permettront d'ameliorer le bien-etre de la population, de pr6venir les risques lies a la sante de la reproduction et de reduire la morbidit6 et la mortalite parmi les groupes vulnerables que sont les enfants, les femmes en age de procr6er et lesjeunes ages de moins de vingt ciaq ans. Ces objectifs, s'ils etaient atteints, devraient aboutir concretement a la reduction des trois mortalites majeures - imnti1e, juvetile et matenelle - grice a (i) un ralentissement de la croissance demographique, (ii) des comportements et pratiques adequats et (iii) une am6lioration des services de sant6 de la reproduction et de sante infntile et juvenile. Pour atteindre ces objectifs de developpement, nous nous proposons de mettre en place, avec I'appui des bailleurs de fonds, parmi lesquels nous esperons que 1'Il)A sera un partenaire majeur, un programme a long terme, lequel comportera trois phases et se terminera en 2010. Cet horizon correspond d'ailleurs a celui du programme de developpement a long terme defini par le Gouvemement dans "La Guinee, Vision 2010", et dont les Politiques Sectorielles de Population et de Sante constituent une part importante. La premiere phase qui debute le programme permettra (i) la mise en place des cadres de fonctionnement et des processus, et (ii) l'execution des activit6s prioritaires definies selon les groupes clbles, les domaines d'intervention et les zones geographiques. Cette premiere phase constitue le Projet Population et Sante Genesique (PPSG) decrit plus amplement ci-dessous. La deuxieme phase consolidera les activit6s et les 6tendra a d'autres domaines, cibles et zones. Enfin, la troisieme phase devra permettre d'assurer la continuit6 et la p6rennisation technique, administrative et financiere du programme. Premiere phase du programme: Le Projet Population et Sante Genesique (PPSG) Les objectifs specifiques du projet sont: (1) I'am6lioration de la sensibilisation sur les questions de population et la promotion des comportements et pratiques adequats et sans danger; (2) l'amelioration de la qualite des services prioritaires de sant6 de la reproduction (pour en augmenter l'utilisation par les groupes cibles) et (3) le renforcement institutionnel pour gerer et coordonner les programmes de population et de sante de la reproduction. Sensibilisation sur les questions de population et developpement. Alors que les prestations de planification familiale sont actuellement disponibles dans pres du tiers des centres de sante, la strategie d'Iuformation, Education et Communication (IEC) concue pour sdmuler et entretenir la demande pour ces services, n'a pas beneficie d'un renforcement proportionneL Par ailleurs, suite a la mise en place des recommandations de la Conference du Caire, La strategie d'EC aura besoin d'etre restructuree pour repondre aux besoins specifiques des groupes cible-g: tj3r 4. C'est ainsi que l'information, qui ameliore la sensi'biisation - poiat de depart du changement de comportement - sera modifiee pour atteindre en premier les personnes sources d'autorit6 (chefs de famille et decideurs) et ,es autres sources d'information reconnues que sont les leaders d'opinion dans chaque couche sociale. Quant au plaidoyer aupres des d6cideurs, il est encore plus recent en Guin6e, puisque introduit en 1996, et aura donc besoin d'etre developpe. Sur le plan lgaI les contraiates juridiques a l'utfflistion des methodes de contraception devraient etre levees lors de la session des lois du Parlement en avril 1998. C'est en effet a ce moment que le Code de la Famille devrait etre adopte sur recommandation de la Commission Sociale et des Lois de l'Assemblee Nationale. Par ailleurs, ayant constat6 I'ampleur de la meconnaissance des femmes de leurs droits fondamentaux et le faible taux de saisine (d6p6t de plaintes) qui en decoule, le Gouvemement a pris les mesures necessaires qui ont abouti a la promulgation d'un decret presidentiel portant creation d'une structure relevant du Ministere des Affaires Sociales denommee "cliniques d'assistance juridique aux femmes". Le programme de "communication pour le changement de comportement" en matiere de sante de la reproduction conportera deux sous-programmes. En ce qui conceme le sous-programme Plaidoyer, le premier volet, qui est prioritaire, concerne les jeunes qui plaident pour les jeumes, avec pour themes centraux la prevention des MSTISIDA, l'6ducation a la vie familiale (EVF) et la contraception. Le deuxi6me volet, egalement prioritaire, conceme les hommes, les pares- cihbataires, les peres de famille et les leaders communautaires, avec pour theme les avantages et les bienfaits de la planification familiale. Le troisieme et demier volet du sous-programme touche les d6cideurs et officiels de haut rang et porte sur les relations entre population et developpement. Le deuxieme sous-programme est constitu6 par des sessions d'information men6es par les communicateurs concues pour augmenter l'information et, partant, la sensibilisation de toutes les couches de la population sur les themes de sant6 de la reproduction et de la croissance demographique. Renforcement de la promotion des comportements sanitaires adequats. Parmi les adolescents et jeunes adultes, le manage et l'activit6 sexuelle precoces sont de pratique courante. Mais la connaissance des MST et des pratiques sanitaires benefiques est insuffisante. Les groupes cibles pour La promotion des comportements sanitaires adequats seront: les 2 millions de jelmes ages de 10 a 24 ans dans toute la Guinee; la majorit6 des hommes et femmes en age de procreer et en union durable; et les parents et personnes iafiuentes dans les communautes: peres et meres, accoucheuses traditionnels, enseignants et les gardiens de la paix (policiers, gendarmes). Le Gouvernement appuiera des activites qui informent et conseillent, tout en etant attrayantes et divertissantes, pour les jeunes adultes en milieux urbain et rural et la mise en oeuvre des etapes de changement de comportement afin que peres et meres de famille, hommes et femmes en age de procreer soient en possession des informations qui leur permettront de choisir et de decider a l'issue des seances de counseling avec les prestataires formes. Le Gouvemement s'attachera aussi a soutenir toutes les actions pour fiiire disparaitre les pratiques traditionnelles nefastes, telles les mutilations g6nitales feminines. Ces pratiques sont condamnees depuis 1989 dans le Code Penal guin6en (article 265). Cependant, les pesanteurs sociologiques font qu'elles demeurent encore r6pandues. Le Gouvernement agira de concert avec les ONG impliqu6es dans ce travail de longue haleine (par exemple, la "Cellule de Coordination des Pratiques Traditionnelles Affectant la Sante des Femmes et des Enfants" ou CPTAFE). Ce travail demandera des efforts soutenus d; sensibilisation ainsi que des strategies novatrices telles le recyclage economique des exciseusesJ 5. Appui aux groupes vulnerables et promotion de la population et la sant6 de la reproduction. Selon les differentes etudes de base et les ateliers realis8s dans le cadre de la preparation du PPSG, les obstacles sociologiques, culturels et religieux demeurent importants et constituent un frein a l'am6lioratIon de la sante genesique et i la reduction de la croissance demographique. Etant donne les grandes difficultes rencontrees pour reduire ces obstacles, qui trouvent leur origine dans les valeurs socioculturelles, les mentalites et les coutumes, le Gouvemement pense qu'un fonds d'Appui pour la Population (FAP) pourra assister les populations guineennes a trouver leurs propres solutions a ces problemes. Le FAP est donc concu pour repondre aux besoins specifiques des communaut6s de base i travers un mecanisme flexible de financement des activites prioritaires d6finies par les communaut6s eles- memes en matiere de population et de sante genesique. Le FAP vise a financer, sous forme de don, les activit6s a caractere social au sein des commimaut6s, pour (i) l'aamelioration de la sante de la mere, de l'enfant et des jeunes et, (ii) le changement de comportement des commnautes pour reduire la croissance demographique. Decentralisation de la gestion des services d'appui aux prestations. Depuis plus d'une d6cennie, le Gouvemement a reussi a mettre en place les bases d'un processus de decentralisation durable qui responsabilise de facon progressive les huit regions. Faute de financement et de renforcement adequats, les r6formes administratives ne sont pas appliqu6es. Bien que normes, standards et procedures en sante de la reproduction aient ete adoptes en 1996, le programme d'Assurance de la Qualite des soins et des services doit encore etre mis en oeuvre dans sa totalite. En plus, les techniques de supervision ne sont pas standardisees pour permettre des comparaisons dans la region et entre les regions. Enfin, bien que le personnel soit inventoriec dans une base de donnees administrative, l'absence d'une base de donnees fonctionnelle sur le personnel rend difficile le suivi des performances et la remise a jour des competences lors des recyclages. L'approvisionnement en produits pharmaceutiques et contracepifs devra etre revu dans sa totalite. Le Ministere de la Sante mettra au point un plan global visant a resoudre les problemes actuels du sous-secteur m6dicaments au cours de l'execution du Projet. Cet effort inclura ine revision de la tarification actuelle dans le Secteur Public de facon a assurer une meilleure rentabilite de celui-ci, reduire les possibilites de transfert de produits fortement subventionnes vers le secteur informel ou priv6 et retablir des conditions de hlbre concurrence. Le fonctionnement des structures logistiques publiques devra etre ameliore. Une attention pardculiere sera apportee a toutes actions visant a ameliorer la situation de la Pharmacie Centrale de Guinee (PCG). En attendant la mise en place de solutions plus globales, qui ne pourra etre r6alis6e que dans des delais relativement longs, la structure logistique PEV/SSP/ME qui approvisionne les programmes en cours et approvisionnera le projet en contraceptifs et autres medicaments essentiels sera renforcee, pour garantir que les niveaux p6riph6riques approvisionnent les populations de maniare adequate. Amelioration des prestations de planification fTmlliale et de la lutte contre les MST/SIDA. L'udlisation adequate de la contraception et partant l'augmentation de la prevalence ne pourra etre accomplie que si les prestations sont mises a la portee de la grande majorit6 des beneficiaires. 11 reste a integrer les prestations*4anification familiale dans deux tiers des centres de sante et les communaut6s environnantes 01 6. Le Ministere de la Sante rappellera les directives stipulant que les services de planification familiale sont subventionnes afin que la tarification appliquee les rende accessible aux groupes vulnerables et aux indigents. II reste cependant a revoir l'echelle des subventions aux medicaments essentiels (y comniris les contraceptifs). Pour reduire la discontinuation de l'utilisation, la qualit6 des services doit non seulement etre maintenue mais encore constamment amelioree. Le Gouvernement appuiera egalement les activites de prevention des MST et leur traitement precoce chez les jeunes de 12 a 24 ans qui ne sont pas en union durable, au niveau des services de sante universitaire et scolaire, au niveau des six cliniques modeIes et au niveau des centres urbains oii il y a des laboratoires de diagnostic et depistage. Etant donn6 le r6le essentiel des centres de stage pratique que sont les cliniques de 1'AGBEF, le Gouvemement continuera a s'appuyer sur cette ONG en lui confiant la mission d'operation de deux autres cliniques modeles. Amelioration des services pour la maternite sans risque, le developpement de la premiere enfance et la prise en charge integree de l'enfant malade. Si les consultations prenatales se sont safisamment developpees, permettant ainsi de detecter les risques au cours de la grossesse, les evacuations suite aux hemorragies ou aux accouchements compliques sont difficiles ou impossibles. Les dix prefectures sur un total de 33 qui ne peuvent pas foumnir de services d'urgences obst6tricales selon les normes requises seront pourvues d'infrastructures et equipements adequats. Le Gouvelmement soutiendra aussi les commumaut6s qui mettront en place un systeme de Mutuelle de Solidarit6 pour les Risques lies a la Grossesse et a l'Accouchement (MURIGA) ou construiront des cases d'attente pour les femmes en situation de grossesse a risque. Le programme national de nutrition qui est actuellement en cours d'execution sera renforce au niveau communautaire, notamment pour les activit6s de contr6le et promotion de la croissance, ou de d6veloppement de la petite enfance, qui sont encore reduites a des iniiatives isolees et de faible envergure. Par aileurs, l'indice synth6tique de f6condit6, estim6 a sept enfants par femme, indique que les naissances sont fr6quentes et nombreuses, autant de facteurs majeurs de malnutrition parmni les femmes guineennes ainsi que de malnutrition, de morbidit6 surajoutee et meme de deces parmi leurs enfants avant l'age de cinq ans. Bien que les endemies majeures dont souffrent les enfints fassent l'objet de programmes de prevention (par exemple, PEV, Lutte contre les maladies diarrhiiques ou contre le paludisme), la formation de la majorite des prestataires a la prise en charge int6gr6e des maladies de 1'enfhnce sera renforcee. Toutes ces activites seront appuyes dans le cadre du PPSG qui apportera son appui a la supervision formative et I'assurance de la qualit6 des soins et services pour la prise en charge integree des maladies de l'enfance. Coordination des politiques et de l'execution du projet. Le lancement de ce programme multi-sectoriel d6crit ci-dessus implique la necessite de disposer de structures de coordination tant au niveau de la mise en oeuvre de la Politique de Population pour la Guinee (PPG) et de la Politique Sanitaire que de I'execution du PPSG. Le Gouvemement s'est deja dote d'une Commission Nationale de la Population et des Ressources Humaines (CNPRH), qui a pour mission essentielle de fornmuler et de mettre en oeuvre la Politique Populaton et toutes les politiques de promotion et de valorisation des ressources humane L1 7. Le Gouvemement prend l'engagement de renforcer le Secretariat Permanent de la CNPRH, et ce avant le demarrage du PPSG, en prenant les mesures suivantes: (a) la defnition precise du role de la CNPRH qui doit assister le Gouvemement a rendre aisement disponible rinfonnation sur les questions de population, diffiuser le contenu de la Politique Nationale de population et coordonner les actions en matiere de population au niveau national, y compris I'anocation des contnbutions des bailleurs de fonds; (b) le. rattachement du Secretariat Permanent de la CNPRH au Cabinet du Ministre du Plan pour renforcer sa credibilit6 et assurer sa visibiLte institutionnelle; (c) la preparation des termes de r6f6rence et des plans annuels d'activites de la CNPRH; (d) l'engagement de r6unir la CNPRH au moins une fois par trnmestre et d'assurer le suivi de ses recommandations; et (e) la mise a la disposition du Secretariat Permanent des ressources necessaires en personnel, soit le Secretaire Permanent (un sp6cialiste en population) et deux autres personnes (un specialiste en techniques de communication et d'IEC et un statisticien/demographe). Ces personnes seront identifiees au sein de la Fonction Publique guin6enne et deployees au Secr*tariat Permanent. En attendant la mise en place de cette capacite, le projet PPSG soutiendra le Secr6tariat Permanent de la CNPRH afin de dynamiser cette demiere. En effet, le PPSG, dont l'execution impliquera des intervenants des diff£rents secteurs, sera mis en oeuvre par un Bureau de Coordination. Cehli-ci comprendra plusieurs specialistes dans les domaines de 1'EEC, de la participation comm uautaire, de la demographie/statistique et des services de sant6 publique, qui apporteront tous un appui technique a la CNPRH Durant ces demieres annees, le Gouvemement de la R6publique de Guine, a entrepris des reformes afin de promouvoir la croissance economique et de reduire la pauvret6. II est cependant n6cessaire qu'un effort soit entrepris pour lancer des progranmnes de population et de sant6 en vue de reguler la f6condit6 globale. Ceci devrait permettre d'etabiir un 6qufibre entre la croissance 6conomique et l'accroissement de la population guin6enne, dans le but d'ameliorer ses conditions de vie. Le Gouvemement pense que le projet Population et Sante Genesique propose ici est l'instrument adequat pour atteindre ces objectifs. Veuillez agreer, Monsieur le President, 1'expression de ma haute consideration. Ministre du Plan et de la Cooperation ° E dlrnoX madou Cellou DLALLO ~ Nwve MAP SECTION E A SiHEtA 12" 10 " GUINEA 80 - - -- - - --T TKed POPULATION AND REPRODUCTIVE HEALTH PROJECT TO Xim,e o ra 12' ISSAU Ma i To Banicko~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~2 Wo0; Daabo / Kal K s- E Niandoko~~~~~~~~~~~~~?4odin G U Il A X:r X C <,, , _>> 1 The boundaries, color5, denominations and any other information AvIID=DIA ( [9\ r° ~~~~~~~~, j ,{1 i11S-gJEI shown on this map do not imply, on the part of The World Bank Group, JLI B ER IA To dl 1 o bdjn ~ gt - ¢ r f ,, - - ~7~~)any judgment on the legal status of any territory, or any endorsement f X rn° AO _ *1 ( R or acceptance ofsuch boundaries. >O '