Project Name Comoros-Health Project... (Previously Second Human Resources Project)

Transcription

1 Report No. PID5951 Project Name Comoros-Health Project... (Previously Second Human Resources Project) Region Sector Project ID Borrower Implementing Agency Africa Basic Health KMPE52887 Government of Comoros Date PID Prepared January 15, 1997 Date PID Revised January 14, 1998 Project Appraisal November 6, 1997 The Ministry of Public Health and Population Moroni, Comoros Tel & Fax: (269) Project Board Date February 26, 1998 Country Background 1. The Comoros is a small archipelago in the Indian Ocean, which has advanced little since independence in 1975 but can do better, even with its modest potential. The economy is largely rural: three-fourths of its population of 504,000 earns its living through agriculture, which also accounts for half of all export earnings. Population growth of about 2.7w a year has far outpaced GDP growth, which averaged 0.6w over Weak macroeconomic management and unresolved structural problems have been to blame, traced, in part, to a highly unstable political environment. Since a multiparty system was introduced in 1990 the country has known at least six changes in government amid several coup attempts, and Cabinet reshuffles every two to three months. In August 1997, the political situation reached crisis proportions when two of the three islands of the Comoros sought independence from the Republic. The Government has since tried to restore the country's unity. Encouraging agreement on national reconciliation has been reached during the national conference in Addis Abeba, organized by the Organization of African Unity in December Such a climate adversely affected the Government's adjustment program launched in Uneven commitment to improve economic management and governance ultimately led to deteriorating public finances and weak private sector response notwithstanding a devaluation of the Comorian franc in January A new government, formed in 1997, has acted to put the adjustment program back on track. The program aims to restore financial stability by reducing the budget deficit, and to accelerate privatization of public enterprises (PEs). Efforts are under way both to improve revenue collection, by restructuring customs administration, and to lower the wage bill, by implementing the 1994 civil service organizational plan and cutting civil servant

2 salaries. On structural reforms, the Government has agreed to move towards privatizing public enterprises in utilities, air and maritime transport, and petroleum imports. To date, the electricity company has been privatized and the air transport company has been liquidated. Notwithstanding progress on technical preparation for privatization, a considerable need exists for strengthening political commitment and public consensus in support of actual program implementation. 3. Against a backdrop of declining real per capita incomes and a government experiencing serious and chronic financial difficulties, the village-level communities of the Comoros have become increasingly self-reliant and have emerged as the primary basis for hope regarding the country's future. These communities have demonstrated cohesiveness and an interest in the development process, a willingness to pay for quality services, and an ability to take responsibility for management. While a recent Poverty Assessment revealed that most Comorians live at near-poverty levels, manifestations of extreme poverty are rare, given a functioning traditional safety net supported through remittances from abroad. Community solidarity being strong, a large majority enjoy access to adequate food, clothing, shelter, basic health care, and water. Sector Background 4. In the health sector, the Government has shown an encouraging commitment to the improvement of the operation and efficiency of the health sector and health facilities by adopting far reaching reforms. Considerable improvements can be noted in terms of the overall organization of the health system, the functionality and efficiency of health facilities, the numbers and responsibilities of health personnel, and community participation in the health sector reforms and cost recovery mechanisms. The Comorian population is now beginning to accept these reforms due to the improved quality of health care and has come to terms with the fact that health care will no longer be free. 5. The health sector's legal framework was significantly improved under the on-going PHR project since a series of legislative texts were adopted between 1994 and For instance, responsibilities at each level of the health care system have been clearly and adequately delineated. Hospitals have been granted autonomy, and day-to-day management of health services is carried out by local teams made up of representatives of both service providers and community beneficiaries. Another law was passed granting all health facilities financial and managerial autonomy. This decentralization with community participation was reinforced by the fact that all health centers currently have community management associations. Hospital management and accounting procedures were adapted to take into account the type of services rendered by each health facility. Even though the reforms provided for management boards to be put in place in all three hospitals, this has yet to take place because of political interference due to the visibility and sensitivity of these positions. IDA is in the process of taking the necessary steps to ensure that these Boards become operational quickly so that - 2-

3 they can efficiently manage the 1998 budgets and review and approve the 1997 accounts of each hospital. The low utilization of health facilities is mainly a supply side phenomenon. A case and point is the El Maarouf hospital (the Comoros' largest hospital) which has put into place the new cost recovery system and has managed to double its receipts in this trend is expected to continue in 1997 and 1998 and then will probably begin to level off in All health facilities have put tarification systems in place which have been approved by MOH. Because of the solidarity that exists in Comorian communities in addition to the cross-subsidization which has began to take place (richer patients subsidizing poorer patients), it is not expected that cost recovery will deter poor population groups from seeking proper health care. However, much remains to be done by MOH to ensure that these reforms have their greatest impact at the level of each health facility. Another means of generating additional funds in the health system are informal twinning arrangements which are taking place between health centers in the Comoros and abroad. For example, the Mbeni Health Center in Grande Comore received an ambulance from a health facility in France. 6. Remarkable progress was made on the personnel front. In parallel with all of these major reforms, MOH adopted a new organizational structure. The types of services to be delivered in each of the country's 17 health facilities was closely looked at in accordance with sector policies and the new orientations of the health system. As a consequence, over 500 non-qualified health workers were laid off. In addition, MOH's skill mix was reassessed and as a result, 75 health workers were to be transferred between the health facilities and 126 licensed health care practitioners were recruited to fill the gaps. Some of these transfers have not yet taken place due to the fact that MOH lacks resources to pay the relocation expenses of health practitioners moving from one island to another. Finally, ten Comorian doctors who returned from abroad after completing their medical studies were hired; therefore, most of the country's health facilities are currently managed by nationals. 7. In parallel with the reform, MOH has initiated efforts to rehabilitate and better equip some of the country's health facilities. In addition, an ambitious training program for health workers that is underway, is financed under the on-going project. However, the main problem that the Comorian health system is faced with is that the Government has not been able to come up with the budgetary allocations for the country's health facilities. In 1995, the European Union provided this financing. In 1996, less than 10 percent of the agreed upon non-wage budget was actually allocated to the MOH. Judging by the trends of the last 10 years, this is a potential problem that could adversely affect the health reform process. Project Objectives 8. The project's overall objective is to reduce the mortality from common diseases, particularly malaria, by ensuring a better utilization of health facilities for the delivery of quality health care to the vast majority of the population and by organizing vector control activities to reduce the incidence of malaria

4 Project Description 9. The proposed project will be implemented over a four-year period and its total cost is estimated at US$10.0 million. The project will have the following components: (a) rehabilitation and equipment of selected health facilities in all three islands; (b) malaria control program; and (c) institutional strengthening of MOH which will include training for health facility as well as MOH staff, studies for the development of alternative mechanisms for health financing, technical assistance for selected public health topics and twinning arrangements with health facilities abroad. Project Financing 10. The total project costs are estimated at US$10.0 million over a four year period. IDA would finance US$8.4 million, beneficiaries would be expected to contribute US$900,000; WHO and UNICEF will contribute $500,000 and $100,000 in parallel financing for the malaria control program. Project Implementation 11. The General Secretary of the Ministry of Public Health and Population will be responsible for the overall supervision of the project (including close follow-up of the on-going health sector reforms) and for overseeing the implementation by MOH directorates and line agencies of the three project components. A project implementation unit (Cellule d'execution du projet - CEP) will also support the implementation of this project and among other things will be responsible for preparing annual work programs and budgets for all activities, ensuring the coordination of the different components, accounting for funds, preparing bidding documents and managing technical assistance contracts. Project Sustainability 12. The project's sustainability will be ensured by improving MOH's overall capacity to manage the sector in an efficient manner and ensure that cost recovery mechanisms are functioning properly in all health facilities in order for these facilities in turn to provide better health services. Through the macro-economic dialogue, it is envisaged that the Government's track record for paying civil servants, including health workers, will improve so that revenues generated through cost recovery are not diverted to pay health workers. Lessons Learned from previous IDA Involvement 13. The Bank is currently financing a Population and Human Resources Project which is expected to close in This project builds on the successful results in terms of attainment of development objectives as well as implementation progress of the ongoing project. The main lesson learned is that the Government is not likely to finance anything except for wages in the sector and therefore alternative mechanisms need to be sought to ensure proper operation of the health sector. Thus, the project has been designed - 4 -

5 for the health sector to be able to function to the maximum extent through cost recovery mechanisms and external financing. Studies in the Comoros show that beneficiaries are willing to pay for health care, provided it is of good quality. Poverty Category 14. The project is part of the program of targeted interventions (PTI). Environmental Aspects 15. The project has been rated "C". There are no major environmental issues. The insecticide to be used for malaria control activities will be selected after it has been approved by WHO; it will have a limited toxicity and will not cause environmental damage. All health facilities to be rehabilitated by the project will have incinerators. Program Objective Categories 16. The proposed project will contribute to poverty reduction and improve the overall health status of the Comorian population. Contact Point: The InfoShop The World Bank 1818 H St. N.W. Washington, D.C Telephone: (202) Fax: (202) Note: This is information on an evolving project. Certain components may not necessarily be included in the final project. Processed by The InfoShop week ending January 30,