AFRICAN DEVELOPMENT FUND REF. N° : CAM/PSHH/2000/01 LANGUAGE : ENGLISH ORIGINAL : FRENCH

APPRAISAL REPORT

HEALTH SYSTEM DEVELOPMENT PROJECT

REPUBLIC OF CAMEROON

NB: This document contains errata or corrigenda (see Annexes).

COUNTRY DEPARTMENT OCDC CENTRAL REGION MARCH 2000

TABLE OF CONTENTS

Page TABLE OF CONTENTS, CURRENCY EQUIVALENTS, WEIGHTS AND MEASURE, LIST OF TABLES, LIST OF ANNEXES, LIST OF ABBREVIATIONS, BASIC DATA, LOGICAL FRAMEWORK, EXECUTIVE SUMMARY 1 PROJECT ORIGIN AND BACKGROUND 1 2 THE HEALTH SECTOR 1 2.1 Health Status of the Country 1 2.2 Sector Policy 2 2.3 Organization of the Sector 2 2.4 Financing of the Sector 4 2.5 Operations by Donors in the Health Sector 4 2.6 Health Infrastructure 5 2.7 Human Resources 5 2.8 Drugs 6 2.9 Sector Constraints 6 3. THE SUB-SECTOR 7 3.1 Health Infrastructure 7 3.2 Health Information System 8 3.3 Maintenance of Biomedical Equipment 9 4 THE PROJECT 10 4.1 Project Design and Formulation 10 4.2 Project Area and Beneficiaries 11 4.3 Strategic Context 12 4.4 Project Objectives 13 4.5 Description of Project Outputs 13 4.6 Detailed Description of Project Activities and Components 13 4.7 Environmental Impact 18 4.8 Project Cost Estimates 18 4.9 Sources of Finance and Expenditure Schedule 19 5 PROJECT IMPLEMENTATION 20 5.1 Executing Agency 20 5.2 Organization and Management 20 5.3 Supervision and Implementation Schedule 21 5.4 Procurement of Goods and Services 22 5.5 Disbursements 23 5.6 Monitoring and Evaluation 23 5.7 Project Accounting and Audit 23 5.8 Coordination of Aid 24

6 PROJECT SUSTAINABILITY AND RISKS 24 6.1 Recurrent Costs 24 6.2 Project Sustainability and Cost Recovery 24 6.3 Major Risks and Mitigation Measures 25 7 PROJECT BENEFITS 25

7.1 Economic Analysis 25 7.2 Analysis of Social Impact 26

8 CONCLUSIONS AND RECOMMENDATIONS 27 8.1 Conclusions 27 8.2 Recommendations and Loan Approval Conditions 27

___________________________________________________________________________ This report has been prepared by Mrs. A. DIOP, Health Expert (OCDC.3), Mission Leader, and two consultants (an architect and a financial analyst), following an appraisal mission to Cameroon in January 2000. Mr. M. A. CISSE, Architect, OCDC.3, contributed to the finalization of the report. Any enquiries relating to this report may be referred to Messrs. L.B.S. CHAKROUN, Director, OCDC (Ext. 4008) and N. SAFIR, Acting Division Manager, OCDC.3, (Ext. 4392).

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CURRENCY EQUIVALENTS

(January 2000) Currency Unit = CFAF (XOF) UA 1 = CFAF 895.165 UA 1 = US$ 1.37095

WEIGHTS AND MEASURES

Metric System

LIST OF TABLES

Tables Page 2.1 Table of Donor Areas of Operation 05 2.2 Table of Health Staff Distribution in Cameroon in 1997 06 4.1 Table of Distribution of Health Facilities in the Project Areas 12 4.2 Project Cost Estimates by Component 19 4.3 Project Cost Estimates by Expenditure Category 19 4.4 Project Cost Estimates by Source of Finance 19 4.5 Expenditure Schedule by Component 20 4.6 Expenditure Schedule by Source of Finance 20 5.1 Provisional Project Implementation Schedule 21 5.2 Procurement Arrangements 22

LIST OF ANNEXES Annexes Number of pages Annex I : Map of Cameroon 1 Annex II : Organization Chart of the Ministry of Health and the PIU 1 Annex III : Implementation Schedule 1 Annex IV : Table of Expenditure Categories 1 Annex V : Detailed Project Costs 3 Annex VI : List of Annexes to the Project Implementation Document 1

FISCAL YEAR

1 July to 30 June

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ACRONYMS AND ABBREVIATIONS

ADB : African Development BankAIDS : Acquired Immune Deficiency SyndromeBD : Bidding DocumentsCAA : Autonomous Sinking FundCAPP : Provincial Pharmaceuticals Supply CentreCENAME : National Essential Drugs and Consumables Supply Centre CIP : Provincial Information Technology CentreCMA : Subdivisional Health CentreCNDS : National Health Development CentreCOGE : Management CommitteeCOGEDI : District Management CommitteeCOGEHD : District Hospital Management CommitteeCOGEPRO : Provincial Management CommitteeCOSA : Health CommitteeCPP : Steering CommitteeDEPI : Studies, Planning and Health Information Division DH : District HospitalDMH : Department of Hospital MedicineECD : District Core TeamEU : European UnionEVP : Expanded Vaccination ProgrammeFSPS : Special Health Promotion FundGPN : General Procurement NoticeHA : Health Area HC : Health CentreHD : Health DistrictHIPC : Heavily Indebted Poor Countries IAPSO : Inter Agency Procurement Services OfficeIB : Invitation to BidICB : International Competitive BiddingIEC : Information, Education and CommunicationIHC : Integrated Health CentreMCME : Essential Drugs and Medical ConsumablesMINEFI : Ministry of FinanceMINHEALTH : Ministry of HealthMINPAT : Ministry of Investments, Property and Regional Development MINTP : Ministry of Public WorksNCB : National Competitive BiddingNHIS : National Health Information SystemONSP : National Public Health ObservatoryPCIEM : Integrated Sick Children ManagementPHC : Primary Health CarePMA : Minimum Activity PackagePNDS : National Health Development PlanREOSSP : Primary Health Care ReorientationSESA : Child Health in the South and AdamaouaSYNAME : National Essential Drugs Supply SystemTAF : Technical Assistance FundTOR : Terms of ReferenceUA : Unit of AccountUNICEF : United Nations Children’s FundWB : World Bank WHO : World Health Organization

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CAMEROON : BASIC DATA COMPARATIVE SOCIO-ECONOMIC INDICATORS

Year Cameroon Africa Developing Countries

Developd Countries

Basic Indicators Total area ('000 Km²) 475 30 061 80 976 54 658Total population (million) 1998 14.3 748.0 4 718.9 1 182.2Urban population (% of Total) 1998 47.5 38.2 39.6 75.6Population density (per Km²) 1998 30.1 24.9 58.3 21.6GNP per capita (US $) 1998 610 663 1 250 25 890Participation by working population - Total (%) 1998 41.0 43.7 … …Participation by working population – Women (%) 1998 15.5 37.0 … …Value of Sex-specific Human Development Index 1997 0.5 0.5 0.6 0.9Human Development Index (Position out of 174 countries) 1997 134 N.A. N.A. N.A.Population living below $ 1 per day (%) 1989-94 ... 45.0 32.2 …Demographic Indicators Total population growth rate (%) 1998 2.7 2.3 1.6 0.3Urban population growth rate (%) 1998 4.6 4.3 3.1 0.6Population under 15 years of age (%) 1998 43.8 42.9 33.2 18.8Population aged 65 and above (%) 1998 3.6 3.3 19.7 26.7Dependency ratio (%) 1998 94.2 86.9 61.7 48.8Male/female ratio (men/ 100 women) 1998 98.7 99.3 103.3 94.8Female population from 15 to 49 years (million) 1998 3.3 176.2 1 213.4 296.8Life expectancy at birth - Total (years) 1998 54.1 52.7 64.0 75.4Life expectancy at birth - Women (years) 1998 55.3 53.4 65.8 79.1Crude birth rate (per 1000) 1998 38.4 37.7 23.8 11.0Crude mortality rate (per 1000) 1998 12.5 13.7 8.4 10.3Infant mortality rate (per 1000) 1998 69.8 80.7 58.9 9.0Mortality rate of children below 5 years (per 1000) 1998 104.0 116.1 76.2 10.4Maternal mortality rate (per 100000) 1996 550.0 698.0 488.0 30.0Total fertility rate (per woman) 1998 5.0 4.9 2.9 1.6

Women using contraceptives (%) 1991 16.1 … 56.0 70.0Health and Nutrition Indicators Number of doctors (per 100000 inhabitants) 1990-97 7 23 76 253Number of nurses (per 100000 inhabitants) 1988-97 50 89 85 780Births assisted by qualified staff (%) 1995-98 58 ... 54 99Access to clean water (% of the population) 1990-97 41 55 72 100Access to medical services (% of the population) 1995 80 60 80 100Access to health services (% of the population) 1990-97 50 45 43 100Percentage of adults from 15-49 years with HIV/AIDS 1997 4.9 5.7 … …Tuberculosis incidence (per 100000) 1995 194 201 157 24Children vaccinated against tuberculosis (%) 1996 53 77 88 93Children vaccinated against measles (%) 1996 43 63 79 90Underweight children under 5 years (%) 1990-97 15 26 31 …Daily calorie intake 1996 2 154 2 406 2 650 3 222Public expenditure on health (in % of GDP) 1995-97 1.0 1.4 1.8 6.3Education Indicators Gross enrolment ratio (%) Primary - Total 1997 97.0 78.3 100.0 103.0 Primary - Girls 1997 69.0 71.2 93.8 103.2 Secondary - Total 1997 32.0 32.7 50.4 100.3 Secondary - Girls 1997 23.0 29.5 45.3 101.8Female teaching staff in primary schools (% of total) 1994 31.7 45.0 51.0 82.0Adult illiteracy – total (%) 1998 27.1 43.5 28.2 1.3Adult illiteracy - Men (%) 1997 21.0 33.0 19.6 1.0Adult illiteracy – Women (%) 1997 35.4 51.6 35.8 1.5Percentage of public expenditure on education 1998 11.6 12.0 10.0 4.0Environmental Indicators Arable land in % of total area 1996 12.8 5.9 9.9 11.6Annual deforestation rate (%) 1990-95 0.6 0.7 0.4 -0.2Annual reforestation rate (%) 1980-90 29.0 4.0 … …CO2 emission per inhabitant (metric tonnes) 1996 0.3 1.1 2.1 12.5Source : Compiled by the Statistics Division from ADB databases; UNOAIDS; World Bank Live Database, Population Division United Nations

Notes: N.A.. Not Applicable ... Data Not Available Last update : December 1999

GNP per capita ( US $ )

0

200

400

600

800

1000

1200

1990 1991 1992 1993 1994 1995 1996 1997 1998

Cameroon Africa

Population growth ratei d l (%)

2.12.22.32.42.52.62.72.82.9

1990 1991 1992 1993 1994 1995 1996 1997 1998

Cameroon Africa

Life expectancy at birth(Years)

4950515253545556

1990 1991 1992 1993 1994 1995 1996 1997 1998

Cameroon Africa

Infant mortality rate(per 000 )

020406080

100120

1990 1991 1992 1993 1994 1995 1996 1997 1998

Cameroon Africa

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AFRICAN DEVELOPMENT FUND

01 B.P. 1387 ABIDJAN 01 Tel. : (225) 20 20-44-44: Fax: (225) 20 20-40-99

PROJECT INFORMATION BRIEF

Date: January 2000 The information given hereunder is intended to provide guidance to prospective suppliers, contractors, consultants and all persons interested in the procurement of goods, works and services for projects approved by the Board of Directors of the Bank Group. More information may be obtained from the Executing Agency of the Borrower. 1. Country : Republic of Cameroon 2. Name of the Project : Health System Development Project in Cameroon 3. Location : Centre and South Provinces 4. Borrower : Republic of Cameroon 5. Executing Agency : Project Implementation Unit,

Ministry of Public Health, Fax n° (237) 23 59 23 - Tel (237) 23 52 25

6. Project Description : The project comprises the following 4

components:

I Strengthening of health services II Strengthening of the Health Information System/Health Observatory III Support for maintenance of biomedical equipment IV Project management

7. Total Project Cost : UA 9.10 million i) Foreign exchange costs : UA 6.99 million ii) Local currency costs : UA 2.11 million 8. Bank Group Loan/Grant ADF : UA 8.05 million 9. Other sources Government : UA 1.05 million 10. Probable date of loan approval by the Bank Group : May 2000

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11. Estimated project starting date

and duration : January 2001 and 48 months 12. Procurement of Goods, Works and Services Civil engineering works: (i) ICB for the rehabilitation works of district hospitals and NCB for the construction of health centres. Goods: (i) ICB for the procurement of specialized equipment/furniture and supplies (drugs and consumables, office consumables) for hospitals, health centres (HC) and National Public Health Observatory (ONSP); (ii) IAPSO for all vehicles and motorcycles to be procured under the project, (iii) NCB for the furniture of structures set up; and (iv) local shopping for the procurement of equipment and furniture as well as office supplies, consumables, fuel and maintenance of PIU vehicles, in view of the small amount for the contract and the existence of enough local suppliers to guarantee competitive prices. Consultancy Services: (i) Competitive bidding on the basis of a short list for the recruitment of a consulting firm to conduct supplementary engineering studies, update bidding documents for civil engineering works, supervise and monitor the procurement of equipment and furniture, and supervise construction/rehabilitation works; (ii) foreign specialized training institutions will be recruited on the basis of a short list (iii) local seminars will be conducted by national experts to be recruited through local invitations for applications from candidates; (iv) technical assistants who will be responsible for the establishment of the various structures will be recruited on the basis of short lists; the same will apply to an audit firm for the auditing of project accounts; (v) the health structures will be revitalized by NGOs to be selected on the basis of short lists with the assistance of UNICEF and GTZ; and (vi) in view of the importance of cultural aspects and the small contract amounts, the studies and surveys will be conducted by local agencies to be recruited on the basis of short lists.

vi Matrix: Cameroon – HEALTH I

Narrative Description (ND)

Verifiable Indicators (IOV) Means of Verification (MV) Major Assumptions

Sectoral Objective: 1. To improve the health conditions of the population

1.1 Mortality and morbidity rates reduced by

at least 20% in 2008. 1.2 Reduction, by 2008, of the prevalence of

major diseases by 20%;

1.1 Annual health statistics reports from

MSP ; 1.2 Activity reports of health units -

supervision reports; MSP statistics

(Sect. obj. to supr. obj.)

Project Objective: 1. To improve

accessibility to and quality of health services in the Centre and South Provinces

1.1 20% increase in the intake capacity of

health units in the Centre and South Provinces as from 2003 ;

1.2 80% of the ONSP data will be reliable and

immediately available for use as from 2003;

1.3 80% of biomedical equipment

maintenance problems in the Centre and South Provinces will be tackled by the staff of health units as from 2004;

1.1 Annual reports and health statistics from

MSP, Activity reports of targeted DHs/HCs;

1.2 Activity reports of the Health Observatory; 1.3 Activity reports of targeted Hospitals/HCs;

(Proj. obj. to sect. obj.) Continued economic crisis in the country. Poor institutional capacity of MINHEALTH. Widespread demotivation of health staff. Continuation of the SNIS, a condition precedent to ONSP. Adherence of population to project objectives.

Outputs: 1. Health units upgraded; 2. Community

participation developed around health structures targeted by the project;

3. A health observatory

established and operational;

4. Maintenance of

biomedical equipment enhanced

1.1 Three district hospitals and six health

centres rehabilitated/ constructed and equipped;

1.2 Twenty-six employees of targeted basic

health centres trained in IEC, micro-planning and maintenance, by 2004;

1.3 An initial stock of essential drugs,

medical consumables and management tools, evaluated at UA 86 000, provided for the health structures of the project as from 2003;

1.4 Two KAP surveys at the start and end of

the project in 2001 and 2004; 2.1 Eighty-four members of dialogue

structures of targeted health units, trained in management and accounting by 2002;

3.1 A KAP survey on the population’s

perception of health services, and a study on the communication system in health districts conducted by 2003 ;

3.2 A Health Observatory established and

equipped, and staff trained by 2003 ; 4.1 Eighty-four maintenance employees in

the Centre and South Provinces trained in maintenance and equipped with tool kits as from 2003;

4.2 Ten provincial and one national workshops on maintenance study organized by 2002;

1.1 Progress reports –ADF Supervision

reports – Equipment delivery vouchers – Project completion report;

1.2 Training reports – Supervision reports –

Activity reports; 1.3 Purchase orders – Delivery orders –

Activity reports –Supervision report 1.4 Survey report 2.1 Training reports – Supervision report –

Activity reports; 3.1 Activity reports – KAP survey reports –Report on study – Supervision report – Report on the study; 3.2 Activity reports of the Observatory –

Training reports ; 4.1 Training reports – Supervision reports- Activity reports; 4.2 Workshop reports– supervision reports- activity reports; Maintenance study report

(Outputs to Proj. obj.) Transfer of staff to the project health structures Effective payment of budget allocations to the health structures Establishment or revitalization of dialogue structures linked to basic health units of the project

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Narrative Description (ND)

Verifiable Indicators (OVI) Means of Verification (MV) Major Assumptions

Activities 1.1 Conduct of

supplementary studies and update of bidding documents of all works and equipment

1.2 Issue and analysis of

bids for works on health infrastructure;

1.3 Recruitment of

consulting firms for the monitoring and supervision of works and enterprise for carrying out the works;

1.4 Invitations to bid for

equipment and orders from essential drugs and consumables;

1.5 Reception of

equipment and orders from essential drugs and consumables;

1.6 Recruitment of survey

consulting firm and conduct of the survey;

2.1 Identification of trainers, and selection of persons to be trained; 2.2 Organization of training seminars; 3.1 Preparation of TOR for studies and surveys; 3.2 Selection of sites for studies and surveys and investigators, and conduct of studies and surveys in the field; 3.3 Preparation and dissemination of reports on studies and surveys; 4.1 Organization of training seminars 4.2 Organization of consensus workshops on maintenance study

Resources in UA million by expenditure category F.E. L.C. Total A. Studies/Superv. 0.46 0.05 0.51 B. Construct/Rehab. 2.66 1.14 3.80 C. Equipt/Supplies 2.31 0.11 2.42 D. Training 0.40 0.22 0.62 E. Tech. Assist. 0.37 0.04 0.41 F. Operating costs 0.08 0.30 0.38 G. Audit of accounts 0.04 0.01 0.05 ---------------------------------------------------------- Base costs 6.32 1.87 8.19 Phys. Conting. 0.31 0.13 0.44 Inflation 0.36 0.11 0.47 --------------------------------------------------------- Grand Total 6.99 2.11 9.10 Financing Plan (in UA million) F.E. L.C. Total ADF 6.99 1.06 8.05 Government - 1.05 1.05 --------------------------------------------------------- Grand Total 6.99 2.11 9.10

1.1 Bank supervision report – Activity reports 1.2 Bid analysis reports/ contracts signed; 1.3 Contracts signed – Monthly accounts –

Audit report – Final implementation report.

1.4 Purchase orders. 1.5 Delivery vouchers – Receiving vouchers –

Supervision report – Activity reports 1.6 Bid opening reports – Report on surveys 2.1 List of trainers and participants 2.2 Training/seminar reports – Supervision report 3.1 TOR of studies and surveys 3.2 List of sites selected and investigators – Activity reports – Study and survey reports – Supervision report 3.3 Study and survey reports disseminated; 4.1 Training/seminar reports – Supervision report; 4.2 Workshop reports – Supervision report

(Act. to output) 1. Promulgation of texts setting

up the Steering Committee and appointment of its members.

2. Disbursements not

suspended, because of arrears.

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EXECUTIVE SUMMARY 1. PROJECT BACKGROUND In 1989, the Bank financed a pre-investment study of the health sector in Cameroon. On the basis of the results of the study and the objectives of the National Health Development Plan (PNDS), and in view of activities already carried out in the targeted areas by other partners, the Government in May 1999 requested ADF assistance in the financing of a project that would cover the priority areas of operation identified by the study. In partnership with the Government, the proposed project has the following components: i) strengthening of health services; (ii) strengthening of the national health information system (SNIS) through the establishment of a Health Observatory; (iii) support for the maintenance of biomedical equipment; and (iv) project management. This project is consistent with ADF VIII social sector priorities, including the development of human capital. It also falls in line with the Bank’s strategy for Cameroon as defined in the CSP 1999-2001 which, for the social sector, consists mainly in improving the living conditions of the population, upgrading human resources, and providing basic infrastructure in landlocked areas. Lastly, the project complies with the objectives of the primary health care reorientation and revitalization policy (REOSSP) and of PNDS 1999-2001. 2. PURPOSE OF THE PROJECT

The ADF loan will be used in financing all the foreign exchange costs and 50.53% of the local currency costs (equivalent to 11.74% of the total project cost), or 88.51% of the total project cost. 3. SECTORAL AND SPECIFIC OBJECTIVES OF THE PROJECT The sectoral objective of the project is to improve the health status of the population, through increased accessibility to integrated and high quality health care for the entire population, and their full participation in the management and financing of health activities. The specific objective of the project is to improve accessibility to and the quality of health services in the Centre and South Provinces by strengthening health services, providing support for maintenance and strengthening the SNIS. 4. BRIEF DESCRIPTION OF PROJECT OUTPUTS

The project has 4 components as follows:

I Strengthening of health services, II Strengthening of the National Health Information System/Health Observatory, III Support for the maintenance of biomedical equipment, and IV Project management.

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The following outputs will make it possible to achieve the project objectives:

- 3 district hospitals rehabilitated and 6 health centres constructed; - 6 health areas revitalized; - Some staff of the health structures targeted by the project, MINHEALTH, health districts

and the Health Observatory trained in various areas of health; - Some members of dialogue structures, especially structures for community participation in

the health drive, sensitized and trained; - Training, sensitization and consensus workshops in the various aspects of the project

organized; - Maintenance of biomedical equipment revitalized and enhanced; - Three modules for training maintenance workers created and operational in three

professional high schools; - Computer equipment and vehicles procured under the project; - An initial stock of essential drugs and consumables provided in health units targeted by

the project; - Studies and surveys conducted on health practices, health services offered to the

population, and the communication system between health districts; and - A Health Observatory established and operational.

5. PROJECT COST The total project cost, exclusive of tax and customs duty, is estimated at UA 9.10 million comprising UA 6.99 million in foreign exchange and UA 2.11 million in local currency. During an implementation period of 4 years, the base cost would record an overall increase of 11.16% (5.43% and 5.73% for contingencies and inflation respectively). 6. SOURCES OF FINANCE

The project will be financed by ADF in the amount of UA 8.05 million and the Government for UA 1.05 million. 7. PROJECT IMPLEMENTATION The project will be managed and coordinated by a project implementation unit (PIU) in close collaboration with the structures of MINHEALTH under whose authority it will be placed. The PIU will be based in Yaounde, and will be provided with the staff required for its smooth running. MINHEALTH will exercise supervisory authority over the project through a Project Steering Committee (CPP) comprising a representative from each of the following Ministries and agencies: MINHEALTH, MINPAT, MINEFI, MINTP, the European Union, GTZ, the health services of the Protestant Church and Coalition of NGOs.

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8. CONCLUSIONS AND RECOMMENDATIONS Conclusion 8.1 The project contributes to the achievement of REOSSP objectives in Cameroon, and meets a genuine need of the population. It also complies with the Bank’s health policy and ties in with a global health services strengthening plan advocated by the donor community. The establishment or rehabilitation of health structures in disadvantaged areas, along with the development of support structures, such the SNIS, and the maintenance of biomedical equipment, will concretely contribute to improving the health status of the population. Recommendations 8.2 In view of the foregoing, it is recommended that a loan not exceeding UA 8.05 million be granted to the Republic of Cameroon, for the implementation of the project. The loan will be subject to the general conditions and the special conditions defined in the loan agreement.

1. PROJECT ORIGIN AND BACKGROUND 1.1 In 1989, the Bank financed a pre-investment study on the health sector in Cameroon with a TAF grant of UA 1.34 million. The study, which started in April 1993, focused on the following areas: (i) the maintenance of biomedical equipment; (ii) health infrastructure; and (iii) health information. On the basis of the results of the study, with a final report in 1999, and the objectives of the National Health Development Plan (PNDS) and in view of the activities already carried out in the targeted areas, the Government communicated the priority areas of operation to ADF. The areas were analyzed by the project preparation mission which went to Cameroon in June 1999. In agreement with the authorities, the following four components were defined: (i) the strengthening of health services; (ii) the strengthening of the health information system (SNIS); (iii) support for the maintenance of biomedical equipment; and (iv) project management. This report has been prepared following the project appraisal mission to Cameroon from 3 to 16 January 2000. 1.2 The project is consistent with ADF VIII social sector priorities, which include the development of human resources through the strengthening of primary health care and basic education. ADF VIII assistance for health lays particular emphasis on primary health care services and information on public health, which are the major areas of the project. Furthermore, the project is in line with the Bank’s strategy for Cameroon as defined in the CSP 1999-2001 which, for the social sector, consists mainly in improving the living conditions of the populations, developing human resources and providing basic infrastructure in landlocked areas. Lastly, it complies with the PNDS the major objectives of which are: (i) to make health districts functional and efficient; (ii) to control the propagation of HIV/AIDS infection through a control programme focused on districts; (iii) to develop and make available to the districts decentralized financing mechanisms for health care and an efficient mutual benefit system for health risks. 2. THE HEALTH SECTOR 2.1 Health Status of the Country 2.1.1 The country’s health situation improved significantly between 1976 and 1987, as portrayed by the life expectancy which increased from 47.2 to 55.2 years. However, life expectancy reduced slightly to 54.1 years in 1998 as a result of the economic crisis experienced by the country between 1987 and 1993; this led to the deterioration of some health indicators. The main causes of morbidity and mortality are malaria, the primary cause of death, followed by broncho-pulmonary infections, anemia, AIDS and heart diseases. However, according to the health map prepared in May 1999, their incidence varies from one province to another. Furthermore, infections such as meningitis and yellow fever are found in Far North and North Provinces. The mortality rates for infants and children above five years old were 69.8 and 104 per thousand respectively in 1998, and were below the African averages of 80.7 and 116.1 per thousand respectively and those of neighbouring countries with infant mortality rates of 97 per thousand in Gabon, 83 per thousand in Congo, and 106 per thousand in the Central African Republic. Considering the country’s economic potentials in comparison to some of its neighbours, efforts made to improve the health indicators are inadequate. As regards the maternal mortality rate, it was 550 deaths for 100,000 life births in 1996, while the African average stands at 698. The proportion of births assisted by qualified staff dropped from 64% in 1991 to 58% in 1998. The total fertility rate was 5 children in 1998 and the proportion of women using at least one contraceptive method, according to the Population and Health Survey in Cameroon (EDSC-II) in 1998, was 24%. This rate was a significant improvement on 1991 when it was 16.1%.

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2.1.2 The vaccination coverage rate in Cameroon is uneven, depending on the vaccination campaigns. In 1996, 53% and 43% of the children were vaccinated against tuberculosis and measles respectively. On average, only 47% of children aged 24 months were completely vaccinated in 1997. This average conceals major disparities between the type of vaccine, the rural and urban areas, and the provinces. The main causes of infant mortality are diarrhea (17.6%), malaria (14.6%), acute respiratory infections (12.9%), measles (12%) and malnutrition (9.1%). 2.1.3 AIDS has assumed alarming proportions, because it spreads in exponential progression. In 1991, 604 AIDS cases were declared, 1 761 in 1994 and 3 950 in 1997, according to the statistics of the AIDS Control Committee. The Committee estimates the number of cases to be about 15,000 today. According to the UNOAIDS epidemiology bulletin of January 2000, AIDS prevalence among the general population stood at 4.9% in 1998. 2.2 Sector Policy 2.2.1 In 1993, Cameroon prepared and adopted a health policy strategy through the “National Primary Health Care Policy Paper” generally referred to as Primary Health Care Reorientation and Revitalization (REOSSP). The objectives of this policy, based on the concept and principles of the Bamako Initiative, are: (i) to speed up accessibility of primary health care (PHC) to all; (ii) to decentralize decision-making in PHC management to the districts; (iii) to promote the decentralized management of community resources, so that the collected funds should remain under their control; (iv) to promote the financial participation of the community in health expenses at all levels of the health system; (v) to ensure substantial financial support by the Government to PHC, through an increase in the national budget allocations to health; (vi) to define an essential drugs policy in line with PHC extension; and (vii) to ensure accessibility by the poorest social groups to PHC through exemptions or subsidies. 2.2.2 To implement this policy, a number of measures and legal instruments have been adopted by the Government upstream and downstream. They include, in particular: (i) the adoption, in 1990, of texts relating to freedom of association and providing a legal framework for dialogue structures, or community participation structures; (ii) the adoption, in 1992, of a national population policy; (iii) the inclusion, in 1993, of AIDS control in IEC (Information, Education, Communication) programmes; iv) the adoption, in 1995, of the decree to organize external health services into health districts, and define their territorial areas of jurisdiction; (v) the adoption, in 1996, of the health outline law; and (vi) the adoption, in 1999, of a PNDS for the 1999-2008 period. The Plan will be enhanced by the Health Sector Plan of Action 2000-2008, under preparation. 2.3 Organization of the Sector 2.3.1 The health pyramid has three levels: the peripheral level corresponding to the health district, the intermediate or provincial level, and the national or central level. 2.3.2 The peripheral level, which is the operational level of health care, comprises 135 health districts and 1,298 health areas. Health care is provided at three levels: (i) the health area which is a well-defined geographical area around a health centre (HC) and which comprises an integrated health centre (IHC) with a minimum package of curative, preventive and promotional activities. Important communication and partnership relations have been established between the HCs and the population, by putting in place dialogue structures. Periodic home visits are organized by the health staff for the population in the most peripheral areas to the HC; (ii) the health district (HD) which has district hospital (DH), the referral structure for HCs, which has a

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higher technical level; (iii) the health district service, which coordinates and supervises all health activities including those of traditional doctors and the private sector. 2.3.3 The Intermediate or Provincial Level which provides technical support for DHs and is responsible for training, refresher courses, supervision, supply of essential drugs, as well as the control and evaluation of DHs in the province. It plays an important role in operational research and technical support, particularly in the maintenance and repairs of equipment and vehicles in the district. A Provincial Management Committee (COGEPRO), comprising senior health staff, representatives of the population and the Government, manages the Special Provincial Health Fund (FSPS). The provincial hospital is the second referral structure for the DH. 2.3.4 The National Level: This level comprises the central administrative structures of the Ministry of Public Health (MINHEALTH) and related national technical structures such as central and regional hospitals. These hospitals are referral structures for provincial hospitals. It is at this level that national health policies, standards and strategies are prepared. The Private Sector The Denominational Private Sector 2.3.5 The private sector is very dynamic in health activities, especially the various denominational private sector comprising mainly the Catholic and Protestant Churches, which provide 43% of the health services in the country. The Protestant Church has 26 hospitals and 100 HCs and dispensaries. They are autonomous and receive external funding. As for the Catholic Church, it has 11 hospitals, 190 HCs and dispensaries and 2 schools for the training of State- registered nurses, staff nurses, midwives and anesthetists as well as nursing aids and assistant laboratory technicians. The State is supposed to give them annual subsidies, but the subsidies are irregular and low. For example, in 1998, out of a total budget of CFAF 4.8 billion for the health services of the Catholic Church, subsidies accounted for 0.52%. The Lay Private Sector (Private Consulting Offices and Clinics, and NGOs) 2.3.6 Private consulting offices are widespread in Cameroon, especially in urban areas. The private sector has 78 general practitioners out of the 658 in the country, 78 clinics and polyclinics, 101 consulting and dental offices and 23 health care offices. 2.3.7 NGOs/Associations, 160 in number, are distributed in all the provinces of the country with, however, more concentration in the Littoral, South-West, Centre and North-West Provinces. Their areas of operation cover, in part or fully, the health sector. Thus, according to a GTZ study: (i) 54.5% operate exclusively in the area of STD/AIDS; (ii) in addition to STD/AIDS, 11.4% deal with reproductive health, especially family planning (FP) and follow-up of youths and adolescents; (iii) 24% generally operate in the area of PHC (vaccination, FP, STD/AIDS, body and environmental hygiene, dental care, campaigns for treatment of common diseases in rural areas and development of water points; and (iv) 10% work in the more general areas of development, mutual assistance and culture. All NGOs generally operate through sensitization activities, counselling, home visits and pair formation. They receive multi-faceted assistance from donors of which they are often primary partners in the field.

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Traditional Medicine 2.3.8 Traditional medicine is quite developed in Cameroon, particularly the use of medicinal plants. In fact, Cameroon has a wide variety of medicinal plants, due to the diversity of its climate and many plant varieties that are relatively well exploited by traditional doctors, based on the administration of raw or processed plants. However, research has not been carried out on these plants to assess their efficiency, dose and harmlessness so as to develop their wide scale production in the form of modern medicines. 2.3.9 Collaboration between traditional doctors and the MSP is developing, especially in health districts where the chief district medical officers are officially responsible for also supervising the activities of traditional doctors. The population has often resorted to this type of medicine, especially in rural areas and among the poor population, because of the high costs of medical care and modern drugs. In fact, according to the UNDP Human Development Report of 1998, which refers to a study (ECAM 96-DSAT), only 36% of poor people who declared that they were ill went to formal structures for consultation as against 24.2% to the traditional doctors. 2.4 Financing of the Sector 2.4.1 Health in Cameroon is funded from three sources: the State, the community and external aid. State funding has declined considerably with the economic crisis. The budget of the MSP dropped from CFAF 28 billion for the 1990/91 fiscal year to CFAF 22 billion in 1995/96, while the proportion in relation to the overall State budget fell from 5% to 3.4% over the same period. This percentage declined further in the 1997/98 fiscal year, despite a higher budget (CFAF 31 billion) in absolute value, and stood at 2.49%, a rate which is far below the 10% recommended by the WHO. The REOSSP policy has compensated for the low budget allocated to health, by enabling the population to participate significantly in the funding of their health. For example, in the Soboum IHC (Littoral Province), proceeds from the sale of drugs and payment for services amounted, in 1996/97 and 1997/98, to CFAF 85 million and CFAF 76 million respectively, which is 9.4 times and 8.4 times the budget of a HC (staff and recurrent expenditure, excluding drugs). The proceeds from drug for the entire Province over the very fiscal years stand at CFAF 582 million and CFAF 572 million. 2.4.2 External aid to the health sector comes mainly from multilateral cooperation (WHO, UNFPA, UNICEF, EEC, the World Bank), bilateral cooperation (Germany, the United States, Belgium, France, Switzerland, Japan and China) and the non-profit private sector comprising international NGOs and local denominational groups. It increased by 38% in 1997 to US$ 27.2 million, comprising US$ 9 million for the construction of hospital infrastructure, US$ 9 million assistance to the PHC sector, US$ 5 million for family planning, US$ 1.2 million for vaccination campaigns, US$ 1.8 million for building the capacities of the Government and grassroots communities, and US$ 1.2 million for various operations (nutrition and IEC, etc.). 2.5 Operations by Donors in the Health Sector 2.5.1 Several donors participate in the implementation of the REOSSP, which currently serves as the operating framework for the health sector. They are, in particular, the World Bank, through its IDA funds, the European Union, Belgium, China, Italy, WHO, UNICEF, AFD, FAC, JURA-Suisse, GTZ, NGOs, Japan and ADB. Table 2.1 below shows the areas of operation of donors in the sector.

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2.5.2 The strengthening of health services and the Heath Information System as well as support for maintenance under the Bank’s project will supplement the activities by other donors towards the overall development of the health system.

Table 2.1: Donor Areas of Operation

DONOR PROVINCES AREAS OF OPERATION UNICEF ADAMAOUA – CENTRE –

EAST – WEST – SOUTH Primary health care (PHC), the Bamako Initiative, consolidation SESA project

European Union CENTRE – EAST – FAR NORTH – WEST

PHC

World Bank CENTRE – FAR NORTH – LITTORAL - WEST – SOUTH

Health, fertility, nutrition, urban health

ADB CENTRE – SOUTH Pre-investment study on the health sector FAC CENTRE- LITTORAL –

NORTH- Rehabilitation of health units, control of transmissible diseases and development-related pathologies, AIDS prevention/control, strengthening of the health system

AFVP CENTRE PHC GTZ LITTORAL – NORTH-WEST-

SOUTH-WEST PHC, essential drugs, maintenance of biomedical equipment, reproductive health for adolescents, AIDS control and social marketing

Japan CENTRE - Medical equipment Italy EAST – FAR NORTH PHC, curative health care Swiss Federal Council LITTORAL PHC in urban centres with emphasis on the revitalization of health districts Swiss Foundation FAR NORTH Reorientation of PHC Jura Suisse CENTRE PHC Belgium FAR NORTH - Institutional support for MINHEALTH at the central and peripheral levels China NORTH Medical and paramedical technical assistance, reinforcement of health infrast. Social Marketing Programme (PMSC)

CENTRE – NORTH-WEST – SOUTH

STD/AIDS control

ONG IEY ADAMAOUA Control of onchocercosis and blindness Carter global NGO NORTH Control of onchocercosis and blindness Other NGOs - PHC, revitalization of health districts, sensitization and training

2.6 Health Infrastructure 2.6.1 The health infrastructure comprises 473 HCs, 775 IHCs, 34 subdivisional medical centres, 68 provincial or general hospitals and 121 DHs. The health system also has 229 pharmacies. Between 80% and 90% of these structures are located in urban and outlying areas. Most of the health infrastructure is dilapidated and much of the equipment is not operating because of old age or breakdowns which could not be handled by the existing maintenance staff. In fact, many hospitals were built in the 1930s and have not been appropriately renovated. In some health facilities, buildings have been gradually abandoned because of their dilapidated state. In some areas, the population has abandoned health units, which were collapsing, and built structures that do not comply with the required standards. 2.6.2 While the quality of health care is acceptable in urban areas which have qualified staff, such is not the case in rural areas mainly because of under-qualified staff. MINHEALTH in 1995 revealed that even though an average of 70% of the population had access to a HC within a 5-km radius, less than 30% used its services. However, in rural areas, HCs operate within a range of 12 to 54 km depending on the provinces. For many women, these distances are the major obstacle to access to health care and vaccination. 2.7 Human Resources

The uneven distribution of health structures is reflected on the allocation of human resources in the health system. In fact, out of the 638 general practitioners in the country only 78, or 12%, are in rural areas. The doctor/population ratio, which was 7/100 000 inhabitants in 1997, is below the WHO standard (10/100 000 inhabitants). However, the nurse/population ratio, which was 50/100 000 inhabitants, is above the WHO standards of 1/7 000 inhabitants

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which corresponds to 15/100 000. Cameroon has 35 health training schools. Table 2.2 below gives a breakdown of the health staff.

Table 2.2: Health Staff Distribution in Cameroon in 1997

A Medical Staff Number B. Paramedical Staff Number C. Administrative

Staff Number

1. General practitioners - Public - Private

580 78

2. Surgeons 65

1. Staff nurses 2 477

3. Pediatricians 39 4. Gynecologists 41 5. Dentists 47

2. State registered nurses 1 526

1. Public Health Administrators

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6. Biologists 9 7. Public Health 13

3. Lab – Techn., Assit. Lab- Techn., Med. Assit.

441 197

8. Internists 15 4. Senior nursing officers 144 9. Pharmacists –Public - Private

21 209

10. Intensive care 2 5. PHC Techn. 36

2. Other staff 73

2.8 Drugs 2.8.1 Drugs are supplied and distributed to public and private non-profit health units by the Centrale Nationale d’Approvisionnement en Médicaments et Consommables Médicaux Essentiels (CENAME) set up in 1997, through the Centres d’approvisionnement pharmaceutiques provinciaux (CAPP). Geographical accessibility to drugs is good throughout the year; the CAPPs are well integrated in the health system. The cost recovery system guarantees equal health care services due to the application of standard prices and the sharing of transport costs and risks. The prices of drugs and consumables are low and fairly stable, and are revised once every year. Nonetheless, not all the social groups can afford them. 2.8.2 The distribution of drugs in health facilities should improve with the consolidation of the achievements of CENAME. In fact, CENAME will be upgraded from a project to an autonomous agency. Given the encouraging results in the low-cost procurement and distribution of drugs by CENAME, UNICEF has just entrusted to it the procurement and distribution of vaccines, and UNFPA has requested the agency to do same for contraceptives. 2.8.3 Furthermore, the Government intends to grant official status to structures participating in the public essential drugs and consumables supply system (MCME) so as to ensure better organization for them. This concerns the FSPS and CAPPs which operate as cooperatives and supply essential drugs (MCME) to health units. Better organization of the drug supply system would, in the medium term, include it in the HD which would be strengthened. In fact, an operational drugs programme will contribute to revitalizing health units by increasing their patient attendance rate, and consequently their income. The CENAME also intends, in collaboration with the Government and donors, to significantly reduce the profit margin of CAAPs for drugs so as to broaden their accessibility for the population. 2.9 Sector Constraints

Generally speaking, the health system is facing the following constraints: • Human Resource Constraints: i) unequal distribution of staff between rural and urban

areas; (ii) the freeze on recruitment in the Public Service; (iii) demotivation of staff following the 50% reduction in salaries and an unsatisfactory professional environment; (iv) shortage of qualified staff in rural areas; and (v) poor reception of the population by

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health staff, which has led to reduction in the number of patients coming to health structures for consultation and treatment.

• Financial Constraints: (i) inadequate State allocations to health, hence the reduction in

investments and lack of maintenance of the infrastructure; and (ii) financial problems faced by the poorest social groups seeking access to health care.

• Institutional Constraints: (i) poor coordination of vaccination campaigns which are not

systematic; (ii) lack of collaboration between central structures responsible for the infrastructure as regards planning, programming and coordination of investments leading to uncontrolled procurements.

3 THE SUB-SECTOR 3.1 Health Infrastructure 3.1.1 There are many health facilities; however, due to their uneven distribution and their high concentration in urban areas, the problem of access to health care by the population is acute, especially in rural areas. This is reflected by the population ratio per hospital bed with the average national ratio at 1/456, while it is 1/271 in the West and 1/806 in the Far North. Constraints on the Health Infrastructure Sub-sector 3.1.2 The health infrastructure sub-sector suffers from the following constraints: • Institutional Constraints: i) unequal distribution to the disadvantage of rural areas; (ii)

lack of a real maintenance policy. The project will establish or reinforce health structures in rural areas. Implementation of the REOSSP by the various health operators contributes to balancing the health system. The small maintenance units to be set up in the project health units will also be responsible for the maintenance of infrastructure.

• Management Constraints: (i) a hospital network not well known, and therefore poorly

managed; (ii) irrational establishment of new operations. The health map being finalized will allow for better knowledge of the hospital network and rational distribution of infrastructure.

• Financial Constraints: i) low capital budget execution rate due mainly to very long and

cumbersome disbursement procedures. As part of the decentralization of the management system for basic health structures, the HDs will enjoy autonomy in the management of their resources and budget.

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3.2 The Health Information System 3.2.1 In 1995, the health information system was upgraded to the National Health Information System (SNIS) for the Management of Health Services. Before then, health statistics were collected and analyzed on various information carriers depending on the regions and agencies operating on the spot. For example, GTZ which was operating in the North-West and the South- West, the SESA Project financed by the USAID, and the Organisation Commune de lutte contre les Maladies Endémiques dans les Pays de l’Afrique Centrale (OCEAC) (Organization of Coordination for the Control of Endemic Diseases in Central Africa), each had its own health information system. Following an assessment of the existing information systems, the Government in 1995 adopted that of SESA as the base for developing the SNIS. 3.2.2 The SNIS was established by the Studies, Planning, Health Information and Information Technology Division (DEPI). The system needs to be developed in line with the health pyramid, from the health districts to the provincial health delegation and finally to the central level. To date, indicators, variables and mediums for the collection of information have been defined for the first level, that is for the public and private denominational HCs. A software has been developed and put in service. The SNIS is operational in HCs as shown by the 1998 activity report. Constraints on the Health Information System Sub-sector 3.2.3 The constraints on the health information system are institutional and financial. • Institutional Constraints: i) conflict of jurisdiction between departments and divisions in

MINHEALTH, as regards health information; each unit feels it is responsible for collecting, processing and using health information, and is reluctant to supply information to DEPI; (ii) lack of coordination between the various operators at the central level as regards implementation of the system; iii) lack of consensus on the system itself, particularly on the type of data to be processed; (iv) the difficulty, for some HCs which cannot provide all the services of the minimum package of activities defined in the REOSSP policy, of supplying the minimum information required by the SNIS; (v) the difficulty, for private missionary HCs, of supplying all the information on their management. However, since the publication of the first annual report (1998) on the implementation of the SNIS in the HCs, the various operators are beginning to understand the utility of the system and accept it. The project provides for activities to strengthen the SNIS through the training of staff responsible for the system at the central and peripheral levels. The establishment of a National Health Observatory (ONSP) will improve coordination of the system.

• Financial Constraints: i) implementation of the SNIS is behind schedule due to

inadequate funds for updating the software for application at higher levels; ii) the computer equipment at the central and peripheral levels is outdated and inadequate, and does not allow for adequate analysis of data. The project provides for assistance to the SNIS in the form of computer equipment for health districts and the DEPI, as well as the training of the staff in these structures in various aspects of health information. In addition, the Government has just made available to the DEPI funds for financing the updating of the software.

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3.3 Maintenance of Biomedical Equipment 3.3.1 Biomedical equipment has, for many years, been procured in a disorderly manner (lack of standard equipment by health structure) and without knowledge of the equipment required by these structures. This has led to excessive or at least huge expenditure on technical and processing equipment. Under the REOSSP, an extensive programme was launched to reform the sector with the objective of improving the cost-effectiveness of health services. Consequently, the Government sought ways of rationalizing health investments in general, and those of equipment in particular. 3.3.2 A number of texts have been issued and measures taken to implement the Government’s desire to control the management of biomedical equipment. The Decree of March 1995 to organize MINHEALTH provides for an Infrastructure and Equipment Sub-Department within the Department Financial Resources and Infrastructure (DEFI). A Consensus Seminar on the Standards of Technical and Processing Equipment in Health Units was held in November 1997, to carry out an inventory of the biomedical equipment required, and prepare standard lists by category of health unit. 3.3.3 According to recent estimates, 75% of all the present biomedical and non-biomedical equipment is not operational, for lack of maintenance and capacity for the diagnosis of causes of diseases as well as lack of qualified staff. However, in the peripheral or intermediate areas, there are a few small-scale maintenance operations supported by the European Union, GTZ, Belgium and local religious congregations. Several other donors participate in solving the problem of maintenance of biomedical equipment, in particular the World Bank, UNICEF, FAC and Japan, by setting up small maintenance units, in addition to equipping health facilities. The Maintenance Private Sector 3.3.4 The maintenance private sector is virtually nonexistent and poorly structured. There are no big maintenance enterprises, but rather medical equipment distributors offering after sales service for the trade marks they represent. The after sales service is often inadequate because spare parts are generally not immediately available and the ordering periods are excessively long. However, small maintenance enterprises are being set up by private individuals. Constraints on the Biomedical Equipment Maintenance Sub-sector 3.3.5 The constraints on the biomedical maintenance sub-sector are as follows: • Institutional Constraints: i) lack of a real biomedical equipment maintenance policy, a

situation which does not favour sustainability of investments; (ii) lack of collaboration between central level structures (DMH and DRFI) in the planning, programming and coordination of investments, which leads to uncontrolled procurement of goods and services without due regard for real needs and maintenance imperatives; (iii) non compliance with the norms and standards relating to the procurement and maintenance of biomedical equipment. The list of equipment in the project HCs and hospitals complies with the norms and standards in force. The study on maintenance, the dissemination of whose results will be financed by the project, will define the bases for a policy thereon.

• Management Constraints: i) lack of a rigorous management system for public health

facilities, which leads to considerable losses; (ii) chronic shortage of consumables and spare parts as well as long delays in their procurement and the virtual nonexistence of

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adequately equipped repair workshops, which results in equipment not being operational for long periods; (iii) lack of a training programme for maintenance employees. The project will set up small maintenance units in the selected health structures. The equipment will be accompanied by a package of spare parts. The creation of 3 training modules in 3 professional high schools in the country as well as the maintenance training proposed in the project will contribute to remedying maintenance problems.

• Financial Constraints: i) inadequate capital budget makes it difficult to replace and

maintain biomedical equipment. The equipment funds in the project will allow for the replacement of some equipment in the project health units and ensure its maintenance.

4. THE PROJECT

4.1 Project Design and Formulation 4.1.1 The project design is based on the objectives of the PNDS and the guidelines of the REOSSP Policy, which primarily aims at broadening accessibility to basic health care for the population. To this end, it lays emphasis on key aspects of the health system such as health infrastructure, the maintenance of biomedical equipment and the health information system. The project is also consistent with the priorities defined by ADF VIII in the social sector in general and the health sub-sector in particular and tallies with the Bank’s strategy for Cameroon for the social sector as defined in the CSP 1999-2001. 4.1.2 The sector donors to whom the project has been presented consider the operation relevant and consistent with the real needs of the population in the targeted rural areas. The project will contribute to the development of HDs through the strengthening of health services and the SNIS in the districts. It will thereby consolidate the activities currently carried out by various donors in the selected provinces and in the other provinces. 4.1.3 With the assistance of NGOs, the project will carry out activities to revitalize the HDs of the Centre and South Provinces where community participation is not very developed. This involves the establishment and revitalization of community participation agencies responsible for co-managing the health structures, training and sensitization of the members of these agencies as well as staff training. Furthermore, the project will initiate collaboration with the private sector in the training of maintenance employees of the public and private sectors. 4.1.4 Furthermore, the preparatory study on the project using a TAF grant has fallen behind schedule because of the unsatisfactory services of one of the selected consulting firms. This risk will be reduced to the minimum during project implementation by providing detailed terms of reference for consultancy services required for the project and closer monitoring of the performance of their contract. Implementation of the project to rehabilitate and equip 6 health units financed by an ADB loan in 1990 was interrupted in 1994, with the consent of the parties during portfolio restructuring, due to financial difficulties faced by the country in 1987. Part of the loan was cancelled and the balance transferred to a structural adjustment programme. 4.1.5 The World Bank encountered difficulties in the implementation of a health sector project. The problems consisted essentially in incompetence of the PIU officials, delays in the allotment of land for the health structures proposed in the project, and the absence of preparatory studies. Lessons will be drawn from this experience as regards project implementation. In fact, the recruitment of senior PIU staff will be entrusted to the Project Steering Committee (CPP). Fixed term contracts will be proposed to this staff. Furthermore, all the land for the proposed infrastructure has already been officially allotted to the project.

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4.2 Project Area and Beneficiaries 4.2.1 The project cover mainly the Centre and South Provinces. The nine health facilities selected are the 3 DHs of AYOS, N’GOG MAPUBI and OBALA in the Centre Province and the 6 HCs of AMVOM, ENDENGUE, AKOM, NGOLBANG, SANGMELIMA I and SANGMELIMA II in the South Province. The 3 DHs, constructed in the 1930s, will be rehabilitated, and the 6 HCs constructed. 4.2.2 Initially, the pre-investment study was to be conducted on 54 health units in 9 provinces. For purposes of efficiency, the Bank requested that coherent groups of activities be proposed in each HD, and that the selection of provinces should take into account regions not covered by the other donors, and the real needs of the population. It was also proposed that 4 of the 6 health structures in the project cancelled in 1994 be included. Consequently, 24 health units in the Centre and South Provinces were selected. The Centre and South Provinces were selected following 2 tripartite (ADB/Government/consultant) consultations in 1994 and 1995. 4.2.3 The appropriateness of the choice of the two provinces was confirmed by the results of EDSC-II in 1998, which showed significant differences in health indicators between the regions, indicators relating mainly to maternal and child health. EDSCII divided the country into 5 regions by grouping the provinces. The Centre/South/East region, which includes the two provinces targeted by the project, generally has lower indicators compared to the other regions. It ranked 4th in terms of the proportion of pregnant women who have received anti-tetanus injection within the past 3 years (81.6% as against 87.5% for the region ranked 1st) and who received the assistance of paramedical staff during delivery over the same period (42.6% as against 77.6%). These indicators have a direct impact on maternal and neonatal mortality. It ranked 5th in terms of the proportion of children from 12 to 23 months who have vaccination cards (46.6% as against 66.4%) and 4th for those who received all EVP vaccines (25.5% as against 53.6%), a situation which affects infant mortality. Furthermore, it ranked 4th in terms of the proportion of married women using contraceptives (21.2% as against 39.4%) and men of the same category (30% as against 58.7%). This situation has an impact on maternal mortality, which is affected by uncontrolled fertility, and on the prevalence of STDs and HIV/AIDS. These differences are often due to the low density of health infrastructure in rural areas. 4.2.4 The final selection of 9 health structures for the project was based on the distribution of health infrastructure in the two provinces, according to the health map of May 1999 and in terms of the results of EDSC- II in 1998. Two criteria underlie the selection of the project sites: (i) the situation in rural areas; (ii) the health infrastructure/population ratio of the province in comparison to that of the respective health districts of the proposed health units. In addition to these criteria, its inclusion in the project cancelled in 1994 was taken into account in selecting the NGOG-MAPUBI hospital.

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Table 4.1 Distribution of Health Facilities in the Project Areas (1999)

Population Health Centres HospitalsA. CENTRE PROVINCE (Rehabilitation of 3 District Hospitals)

2 003 993 220 62

Population/health infrastructure ratios 9 109 32 3221. ESEKA Health District: (NGOG-MAPUBI District Hospital) 74 850 22 3 Population/health infrastructure ratios 3 402 24 950

2. AYOS Health District: (AYOS District Hospital) 42 883 7 1 Population/health infrastructure ratios 6 126 42 8833. OBALA Health District: (OBALA Health District) 99 494 10 3 Population/health infrastructure ratios 9 949 33 165B. SOUTH PROVINCE (Construction of 6 Health Centres) 428 242 143 27

Population/health infrastructure ratios 2 994 15 8601. SANGMELIMA Health District: (3 Health Centres) (SANGMELIMA I HC, SANGMELIMA II HC and NGOLBANG HC)

72 392 20 5

Population/health infrastructure ratios 3 619 14 4782. EBOLOWA Health District: (2 Health Centres) (ENDENGUE HC and AMVOM HC)

142 199 44 6

Population/health infrastructure ratios 3 231 23 6993. LODOLORF Health District: (1 Health Centre) (AKOM HC) 40 635 10 3 Population/health infrastructure ratios 4 063 13 545

4.2.5 The national Health Observatory (ONSP) will be located in Yaounde. In this respect, specific support in terms of training and computer equipment will be provided to the SNIS in health districts. Concerning the “support for maintenance” component, employees from the Centre and South Provinces will be trained in maintenance, and 3 training modules for maintenance will be introduced in 3 professional high schools in Cameroon. Lastly, a project implementation unit will be set up and equipped in Yaounde. 4.3 Strategic Context 4.3.1 With a human development index of 0.536, Cameroon is ranked 134th out of 174 countries, according to the UNDP Report of 1999. An extensive reform programme, initiated in 1997, is supported by an IMF Enhanced Structural Adjustment Facility (ESAF) which is currently in its 3rd year of implementation, the Structural Adjustment Programme (SAP II) of the Bank which has been fully disbursed, and the Structural Adjustment Credit (SAC) of the World Bank under implementation. This assistance has enabled Cameroon to be committed to make poverty reduction a priority. This commitment oriented the 1996/97 budget towards investments in rural infrastructure, health and education. It also resulted in the Government adopting a poverty reduction strategy paper in December 1998. The strategy was defined in consultation with the various ministries, development partners, the civil society and the private sector. It reflects the Government’s utmost desire to reduce poverty and improve growth. The major strategies of the paper include the fight against food insecurity, improvement of access to essential social services, the definition and implementation of an employment policy in line with the realities of the country, good governance and the establishment of a reliable information system for monitoring and evaluating social indicators. 4.3.2 In the negotiations with Cameroon, for the country to be eligible for the debt relief for Heavily Indebted Poor Countries (HIPC), the Government should define, before 30 June 2000, sustainable sectoral plans of action that are consistent with the real needs of the country. The Health Sector Plan of Action is currently being prepared, and a commission presided over by the Minister of Health and comprising representatives from MINHEALTH, GTZ, the World Bank and the WHO has been set up for the purpose. The plan of action, which will be submitted to the various health operators in a consensus workshop, will serve as the conceptual framework for the implementation of PNDS 1999-2008.

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4.4 Project Objectives The sectoral objective of the project is to improve the health conditions of the population through increased accessibility to integrated and high quality care for the entire population and with their full participation in the management and financing of health activities. The specific objective of the project is to improve accessibility to and the quality of health services in the Centre and South Provinces by strengthening health services, providing assistance for maintenance and strengthening the health information system. 4.5 Description of Project Outputs

The project outputs are: - 3 DHs rehabilitated and equipped and 6 HCs constructed and equipped; - 6 health areas covered by the 6 HCs of the project revitalized; - 3 DHs provided with planning capacity for emergency obstetric services; - 12 employees of the project health units trained in maintenance; - 84 members of dialogue structures of health units of the project trained in IEC; - 1 sensitization campaign for national health officials on the SNIS and ONSP and 2

training workshops for trainers on health information organized; - a training/refresher course seminar in information technology for staff responsible for

health statistics organized; - 8 chief district medical officers trained in resource and statistics planning methods; - 2 senior staff of the SNIS and ONSP trained in health information and management of

information systems and 1 ONSP official in public health/epidemiology; - 84 maintenance employees in the Centre and South Provinces (3 per health district)

trained in biomedical maintenance; - 3 professional high schools developed and equipped for the creation of a training module

in biomedical maintenance; - 3 maintenance training modules opened in 3 professional high schools and 9 teachers

from these 3 high schools trained in the training of maintenance trainers; - 10 provincial workshops and a national consensus workshop on the report of the study on

maintenance organized ; - 8 vehicles and 26 motorcycles procured under the project; - 1 Health Observatory established, equipped and operational; - 3 field trips organized for employees of MINHEALTH, the SNIS and ONSP; - an initial stock of drugs supplied to 3 DH and 6 HCs; - 2 surveys on the knowledge, attitudes and practices (KAP) of the population as regards

health at the project start-up and completion conducted in the project areas; - a survey on the population’s perception of health services conducted; and - a study on the communication system between the districts conducted. 4.6 Detailed Description of Project Activities and Components 4.6.1 The project has four components as follows:

I Strengthening of health services II Strengthening of the Health Information System/Health Observatory III Support for the maintenance of biomedical equipment IV Project management

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4.6.2 These components will be implemented under the following expenditure categories:

A Studies and supervision B Construction/Rehabilitation C Equipment/Supplies D Training E Technical Assistance F Operating Costs G Audit Component I: Strengthening of Health Services

4.6.3 This component is intended to strengthen basic health services through the rehabilitation of three DHs and the construction of six HCs. It will broaden access to basic health structures for the population of the Centre and South Provinces, particularly those in disadvantaged rural areas. 4.6.4 Studies and Supervision: The engineering and architectural studies as well as the bidding documents (BD) including topographical and geotechnical studies on the sites for the rehabilitation of DHs and construction of HCs are available in MINHEALTH. The BDs for the construction/rehabilitation works, equipment/supplies, essential medical drugs and consumables (MCME), training and technical assistance as well as works supervision and control will be updated in line with any necessary adjustments. The updating of BDs as well as works supervision and control and the installation of equipment, furniture and supplies will be carried out by a multi-disciplinary consulting firm. 4.6.5 In accordance with paragraph 6.1.11 of the ADF VIII loan policy guidelines, impact assessments will be conducted in the project areas. These include, in particular, two health knowledge-attitudes-practices (KAP) surveys, the first of which will be conducted at project start-up in order to assess the health practices of the population in general and those of the poor in particular, and the second, three years after project start-up in order to assess the impact of the project on the population. In view of the importance of the cultural aspects of these assessments, they will be conducted by local agencies. 4.6.6 Construction/Rehabilitation: Rehabilitation works will concern the renovation of existing buildings, the repairs or reconstruction of frameworks and roofs, special works to improve the functionality of premises and floor and wall finishing. They also concern internal and external painting, repairs or resumption of woodworks, refitting or renovation of technical installations (electricity, sanitary plumbing and air-conditioning). Extension works (construction of technical blocks such as surgery, X-ray, maternity, etc) have also been scheduled for the Obala hospital. 4.6.7 Equipment/Supplies: Project DHs and HCs will be supplied with medical, technical, and non-specialized equipment, furniture, computer equipment, electrical generators, and lightning protection system. Four ambulances will also be procured for the 3 hospitals of the project. The lists of equipment and related BDs will be updated by the consulting firm. Supplies (drugs, medical consumables, office and computer supplies and consumables) will be provided to the project DHs and HCs. They will enhance the smooth running of the various services. 4.6.8 Training: The project provides for the training of the staff of DHs and HCs and members of their community management agencies, as well as for HD officials responsible for

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supervising the structures. Most of the training falls within the plans to revitalize health areas as defined by the Government. It consists mainly in training/refresher courses in: (i) maintenance, for 12 employees from targeted health units - 2 per DH and 1 per HC; ii) REOSSP for staff of health areas and members of dialogue structures, NGOs, local associations and women’s groups; (iii) in IEC/sensitization on emergency obstetric care for community leaders and members of dialogue structures, (iv) primary health care, emergency obstetric care and integrated management of sick children for medical, paramedical and laboratory/blood bank staff of the three DHs. 4.6.9 The programmes and modalities for the training courses will be defined in a detailed plan to be prepared by the PIU. The detailed plan and CVs of candidates for training courses abroad will be submitted to the Fund beforehand for approval. 4.6.10 Technical Assistance: The services of local NGOs will be required for carrying out revitalization activities in health structures. They will schedule, organize and conduct training/sensitization sessions for members of dialogue structures, community associations and staff of health structures in IEC, community/microplanning diagnosis, REOSSP, obstetric emergency care and integrated management of sick children.

Component II: Strengthening of the Health Information System/Establishment of a National Public Health Observatory (ONSP)

4.6.11 This component seeks to provide MINHEALTH with an updated, reliable and efficient information tool for better control of health data, proper epidemiological supervision and fast and appropriate decision-making. The ONSP will enable MINHEALTH to know the expectations of the population as regards health services, and provide appropriate solutions to their concerns. It will also develop intersectoral collaboration with the other ministries concerned with the health of the population (education, environment, water supply, transport and equipment, etc.). It will be located within the National Health Development Centre (CNDS) under the supervisory authority of the Higher Health Council. 4.6.12 The objective of the ONSP will be to gather socio-health data from the entire country relating to health statistics, the health requirements of beneficiaries, and the responses of health structures to these requirements. It will also include data relating to the attitudes and practices of health professionals towards customers, the influence of some socio-cultural and economic variables on the attitude of the populations towards disease, the cycles of some diseases and their geographic prevalence. The data will enable the ONSP to define major guidelines of operation programmes as regards health care and sensitization, and to quickly detect epidemics and take the most appropriate measures to eliminate them. 4.6.13 The project will assist the Government in establishing the ONSP, providing computer equipment and office furniture, and training its staff. The staff required for starting the ONSP activities will consist of a public health doctor, 1 economist, 2 statisticians, 2 computer experts (hardware and software), two demographers, 1 sociologist, 2 communication network technicians, 2 epidemiologists and support staff. MINHEALTH intends to redeploy the staff of existing structures to the ONSP.

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4.6.14 Studies and Supervision: The third national survey on a representative sampling of the different geographical zones, ethnic groups and cultures will be conducted at project start-up on the population’s perception of health services, disease and its causes in general and on the customers’ expectations from the workers. The general objective of the study is to assess the opinions of beneficiaries of health services on the quality of health services, the management of health units and their needs. The objective is to identify and prioritize the needs and aspirations of the beneficiaries of the health system as well as to strengthen the operating capacity of MINHEALTH through the introduction of instruments and methods for permanently assessing the degree of satisfaction of grassroots communities. This survey will be conducted by a local consulting firm specialized in socio-anthropological surveys. Concurrently, a study will be conducted on the communication system in districts in order to assess the efficiency of the system in comparison to SNIS requirements. Lastly, the ONSP will be evaluated during the 4th year of the project; this will make it possible to assess its strengths and weaknesses and take corrective measures. 4.6.15 Equipment/Supplies: The Health Observatory will be provided with equipment, computer equipment and furniture as well as office supplies, computer consumables and software on the processing of health statistics. A cross-country vehicle will also be provided to the long-term technical assistant in the structure. 4.6.16 Training: In order to draw on other African experiences in the establishment and operation of health observatories, 3 field trips will be organized for the Director and Head of the Communication Networks Department in the ONSP, the Director of DEPI and the Inspector General of Health. Training will also be provided in various aspects of health information for the staff of the ONSP and HDs. The training will consist in: (i) a sensitization seminar on the SNIS and the ONSP for health officials at the national level; (ii) 2 workshops for the training of trainers at the provincial and district levels on health information in the health districts and areas; (iii) 2 training/refresher courses seminar on information technology and health information for the staff responsible for recording and analyzing health statistics in the project HDs; (iv) education grants for 3 months for 8 chief medical officers in the project HDs in resource planning methods and in the use of statistical and epidemiological tools; (v) 2 long training courses for 1 senior staff of DEPI and 1 senior staff of ONSP on health information and management of information systems; (vi) the training of 1 ONSP senior staff in public health/epidemiology. Furthermore, a number of consensus workshops on SNIS at the provincial and national levels. 4.6.17 Technical Assistance: The ONSP will benefit from the services of a long-term consultant for 24 staff/months (S/M); the consultant will be an expert in health information systems and will assist ONSP officials in promoting its activities and establishing a functional and viable structure. An information technology expert will also be recruited for 12 S/M and a communication systems experts for 6 S/M.

Component III: Support for Maintenance of Biomedical Equipment 4.6.18 This component consists in enhancing human resource development in maintenance through the training of maintenance workers and technicians. This need for human resources was identified by the pre-investment study and partners working in the area of maintenance. The project will also intervene during the dissemination and implementation of the results of a national study on the maintenance of biomedical equipment. This study which will start soon, is financed by the Government. It seeks to analyze maintenance needs in terms of maintenance services and human resources and training. The needs will concern health units in both the public and private sectors.

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4.6.19 Construction/Rehabilitation: With respect to the introduction of biomedical maintenance training modules in 3 high schools, the premises of the said high schools will be developed. 4.6.20 Equipment/Furniture/Supplies: A package of equipment and spare parts will be procured by the project for the training activities provided for in the training modules to be created in professional high schools. A minor maintenance equipment kit will also be supplied to the structures to which the maintenance employees to be trained belong in the Centre and South Provinces. 4.6.21 Training: The project will finance the training of 84 maintenance employees in the two provinces (Centre and South). The training will be organized locally in the form of 3 workshops (1 in the South and 2 in the Centre) and will concern 3 employees per HD from the public and private sectors. The training of employees from the private sector is justified by the fact that this sector provides 43% of the health services. In addition, 3 senior biomedical maintenance technicians will be trained abroad, and the introduction of 3 biomedical maintenance training modules for workers will be financed in 3 professional high schools. Moreover, the project will finance the provincial workshops and the national consensus workshop on the report of the national study and the dissemination/multiplication of the final report. The study will prepare a national maintenance policy and define strategy for the management of needs identified in the health units of the public and private sectors. It will also make an analysis of the institutional support needs and, if necessary, financial requirements of the structures identified to carry out the maintenance of biomedical equipment, and propose actions to reinforce it. Component IV: Project Management 4.6.22 A Project Implementation Unit (PIU) will be established within MINHEALTH and placed under its supervisory authority. It will be responsible for coordinating project activities and liasing between the Government and the Bank. The establishment of the unit is justified by the fact that the two services likely to host the PIU, in particular the DEPI and the Department of Infrastructure, are structurally inadequate to monitor project implementation. To ensure sustainability of the project and strengthen the capacities of the said services, their staff will receive training in various areas of health information, management and maintenance of biomedical equipment, and public health; furthermore the structures will be equipped. The Government will bear 76.7% of the operating costs of the PIU, including all the salaries of the PIU staff. 4.6.23 Equipment/Supplies: The project will provide the PIU with two saloon cars and one vehicle 4x4, office and computer equipment, and office furniture. 4.6.24 Technical Assistance: A health information consultant will assist the PIU in the preparation of surveys for 6 S/M. An information technology expert will also be recruited for 3 S/M for the procurement of computers. 4.6.25 Operating Costs: The operating costs of the PIU include maintenance/insurance expenses for ADF-financed vehicles as well as travel expenses for staff and communication, salaries, offices supplies and water/electricity financed by the Government.

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4.6.26 Audit: An audit firm will be recruited to audit project accounts. There will be four annual audit missions, one at the end of each year of the project. 4.7 Environmental Impact 4.7.1 The project is classified in Category II. The project, as designed, will not have any major negative impacts on the environment. The sites are appropriate because they are located out of environmentally sensitive areas. The works entail very little earth works, and the probabilities of causing erosion are virtually nonexistent.

4.7.2 Positive Impacts: The project will improve the health and hygiene practices of the population. It will contribute to increasing productivity and economic growth. It will improve the nutritional status of children through better monitoring. It will create jobs during the construction works and thereafter. 4.7.3 Negative Impacts: The following negative impacts have been taken into consideration: (i) nuisance such as noise, dust and traffic disruption as a result of construction works; (ii) destruction of fauna, flora and habitats; (iii) change in the land configuration; and (iv) the production of medical wastes which require special processing. 4.7.4 Mitigation Measures: The facilities will be constructed in compliance with standards relating to sanitation and the processing of biomedical and domestic wastes. Wastewater will be treated in septic tanks and treatment wells before disposal. There is provision for a rainwater drainage system and incineration of biomedical wastes produced by the project health units. The incinerators will be constructed in appropriate areas so as to avoid creating nuisance for the surrounding population. During the works, specific measures will be taken to reduce nuisance such as noise, dust and traffic disruption. The works will be monitored by an expert from the Ministry of the Environment. 4.8 Project Cost Estimates The total project cost, exclusive of tax and customs duty, is estimated at UA 9.10 million comprising UA 6.99 million in foreign exchange and UA 2.11 million in local currency. An overall increase of 11.16% (5.43% and 5.73% for contingencies and inflation respectively) has been applied to the base cost. The costs were determined during the appraisal mission on the basis of information gathered from the Ministry of Health and the Ministry of Public Works. Tables 4.2 and 4.3 below summarize the project costs breakdown by component and by expenditure category respectively. The detailed costs are presented in Annex V.

Table 4.2: Project Cost Estimates by Component

CFAF million UA million COMPONENTS F.E. L.C. Total F.E. L.C. Total % F.E.

1 Strengthening of health services 4,287.31 1,068.70 5,356.01 4.79 1.19 5.98 80.05% 2 Strengthening of the Health Information System 609.67 107.20 716.93 0.68 0.12 0.80 85.04% 3 Support for maintenance of biomedical equipment 528.66 172.99 701.65 0.59 0.19 0.78 75.35% 4 Project Management 237.11 316.04 553.15 0.26 0.35 0.62 42.86% Total Base Cost 5,657.77 1,669.97 7,327.74 6.33 1.86 8.19 77.28% Contingencies 276.33 121.51 397.85 0.31 0.14 0.44 69.46% Inflation 319.86 100.40 420.26 0.36 0.11 0.47 76.11% Total Project Cost 6,253.96 1,891.89 8,145.85 6.99 2.11 9.10 76.77%

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Table 4.3: Project Cost Estimates by Expenditure Category

CFAF million UA million EXPENDITURE CATÉGORIES F.E. L.C. Total F.E. L.C. Total % F.E.

A. Studies and Supervision 410.40 45.60 456.00 0.46 0.05 0.51 90% B. Construction / Rehabilitation 2,380.71 1,020.30 3,401.01 2.66 1.14 3.80 70% C. Biomed. equip./supplies 2,066.55 97.38 2,163.93 2.31 0.11 2.42 96% D. Training 362.12 194.99 557.10 0.40 0.22 0.62 65% E. Technical Assistance 333.45 37.05 370.50 0.37 0.04 0.41 90% F. Operating Costs 67.64 270.56 338.20 0.08 0.30 0.38 20% G. Audit 36.90 4.10 41.00 0.04 0.01 0.05 90%

Total Base Cost 5,657.77 1,669.97 7,327.74 6.32 1.87 8.19 77.21% Contingencies 276.33 121.51 397.85 0.31 0.13 0.44 69.46% Inflation 319.86 100.40 420.26 0.36 0.11 0.47 76.11% Total Project Cost 6,253.96 1,891.89 8,145.85 6.99 2.11 9.10 76.77%

4.9 Sources of Finance and Expenditure Schedule 4.9.1. The project will be financed by the ADF and the Government, as indicated in Tables 4.4 and 4.6 below:

Table 4.4: Project Cost Estimates by Source of Finance

(in UA million)

SOURCES For. Exch. %tage Local Curr. %tage TOTAL %tage ADF 6.99 100.00% 1.07 50.53% 8.05 88.51%

GOVERNMENT 0.00 0.00% 1.05 49.47% 1.05 11.49% TOTAL 6.99 76.77% 2.11 23.23% 9.10 100.00%

4.9.2 ADF contribution, amounting to UA 8.05 million, accounts for 88.51% of the total project cost and covers all the foreign exchange costs and 50.53% of local currency costs, representing 11.74% of the total project cost. 4.9.3 ADF participation in the financing of local currency costs is justified by the objective of enabling vulnerable social groups to have access to health services and, in particular, by: (i) the use of considerable local labour in construction, which accounts for 47.21% of the total project cost; (ii) organization of several local training seminars under the project; (iii) the Government’s efforts to achieve national development and mobilize external and domestic resources for the financing of its development programme; (iv) generally speaking, external aid for the country is essentially used in financing the local costs of programmes, due to lack of adequate local savings; (v) the amount of foreign exchange to finance local currency expenditure is equivalent to 11.74% of the total project cost.

Table 4.5: Expenditure Schedule by Component

(in UA million)

COMPONENTS 2001 2002 2003 2004 Total 1 Strengthening of health services 0.15 3.83 2.66 0.03 6.68 2 Strengthening of the Health Information System 0.16 0.39 0.32 0.00 0.87 3 Support for maintenance of biomedical equipment 0.00 0.86 0.00 0.00 0.86 4 Project Management 0.25 0.16 0.14 0.14 0.68 Total Project Cost 0.56 5.24 3.12 0.18 9.10

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Table 4.6: Expenditure Schedule by Source of Finance (in UA million)

SOURCES 2001 2002 2003 2004 Total ADF 0.50 4.64 2.76 0.16 8.05 GOVERNMENT 0.06 0.60 0.36 0.02 1.05 TOTAL 0.56 5.24 3.12 0.18 9.10

5. PROJECT IMPLEMENTATION 5.1. Executing Agency The project will be managed and coordinated by a Project Implementation Unit (PIU) placed under the authority of MINHEALTH. The PIU will be based in Yaounde in premises provided by the Government and will be assigned the required staff for its functioning. The PIU will comprise a coordinator (health administrator or health economist or health planning specialist), a civil engineer, a biomedical engineer, an accountant, two secretaries, 3 drivers, one messenger and one security guard. The senior staff of the PIU will be recruited through local invitation for applications. The Project Steering Committee (CPP) will select the candidates. The names of the shortlisted candidates and their CVs will be submitted to ADF for approval before the final selection. Contracts will be proposed to these employees. The support staff will be recruited by the Government. 5.2. Organization and Management 5.2.1 The project will be managed by the PIU. MINHEALTH will perform its project control and supervision duties through the Steering Committee comprising a representative from each of the following ministries and agencies: MINHEALTH, MINPAT, MINEFI, MINTP, the European Union, GTZ, the health services of the Protestant Church and the Coalition of NGOs. The Steering Committee will be presided over by the Inspector General of Health. It will meet every three months to assess project implementation, discuss any management problems and find solutions for them. If necessary, the Committee shall hold extraordinary meetings. PIU disbursement requests and bills will be endorsed by the Inspector General of Health before they are submitted to ADF or the Autonomous Sinking Fund (CAA). The Chairperson of the CPP will hold a monthly coordination meeting with the team of PIU senior staff and project consultants under contract. Furthermore, the PIU will work in close collaboration with the DEPI to strengthen the information system, the DMH as regards support for maintenance, and the Department of Financial Resources and Infrastructure to strengthen health services. 5.2.2 The specific responsibilities of the PIU are as follows: - coordinate all project activities; - ensure the administrative and financial management of project components; - supervise the engineering studies, preparation and issue of BDs relating to civil

engineering works and the procurement of equipment/furniture/supplies as well as works implementation, and the delivery and installation of equipment;

- organize and monitor the various training programmes; - prepare disbursement requests, as well as prepare quarterly activity reports and project

audit reports, and transmit them to ADF; - liaise with ADF; and - prepare the project completion report.

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5.2.3 The senior staff of the project will be recruited under the conditions defined in 5.1. The Coordinator will be responsible for all matters relating to the implementation of the entire project: supervision of the activities of the consulting firm and consultants, scheduling of construction/rehabilitation works, and procurement of equipment, furniture and supplies for the units in the institutions concerned. He/she will participate in the issue of invitations to bid, the analysis and evaluation of bids relating to the procurement of the goods and services under the project. He/she will be responsible for the administration of all contracts of the project. He/she will establish official contacts between the project and other Government services, and will be assisted by two engineers and an accountant. 5.2.4 Furthermore, the PIU will be allocated the financial and material resources required for its smooth running and will have two bank accounts into which will be deposited ADF funds for project management and the Government’s counterpart contribution respectively. 5.2.5 The various procedures manuals relating to disbursements, the procurement of goods and services, accounting and cash management will be made available to the PIU. PIU staff will be trained on these procedures during Bank field missions or trips to the Bank headquarters. 5.3 Supervision and Implementation Schedule Project implementation will cover 4 years starting from 2001. The provisional schedule is shown in Table 5.1 below.

Table 5.1: Provisional Project Implementation Schedule

Activities Dates Responsible Board approval May 2000 ADF Entry into force Jan. 2001 ADF Recruitment of consulting firm Sept-Dec. 2000 PIU Prep. BDs for PIU equipment and furniture Jan. 2001 PIU Local shopping for PIU equip./furniture Feb. 2001 PIU Bid analysis for PIU equipt. /furniture March 2001 PIU Delivery of PIU equipment and furniture April 2001 Suppliers Architectural and engineering studies Approval of BDs for construction /rehabilitation June 2001 ADF Invitation to bid for construction /rehabilitation July – Aug. 2001 PIU/Cons. firm Approval of contract award for construction /rehab November 2001 ADF Construction / Rehabilitation works Jan. 2002-Dec. 2002 Enterprises Supervision of works Jan. 2002-Dec. 2002 PIU/Cons. firm Acceptance of construction /rehabilitation Dec. 2002-Jan. 2003 PIU/Cons. firm Mid-term review Feb. 2003 ADF Preparation and approval of lists of equipt./ furniture/ drugs /Biomed. consum. Nov-Dec 2001 PIU/Cons. firm Invitations to bid equip./furn./drugs/bio. cons. March-April 2002 PIU/Cons. firm Analysis of bids equip./furn./drugs./bio. cons. May-June 2002 PIU/Cons. firm Delivery equip./furn./drugs./biomed. cons. Sept-Dec. 2002 Suppliers Units July 2001- June 2004 PIU Technical assistance April 2001- June. 2004 Consultants Operating costs Jan. 2001-Dec.2004 PIU Audit of accounts Dec. 2001- Dec. 2004 Audit Firm Conduct Studies/Surveys Std 1: April-01, Sty 2: Aug.-01 Firms

Std 3:Apr.-Jun-02, Std 4: June 04 Firms Project completion Dec. 2004 PIU

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5.4 Procurement of Goods and Services 5.4.1 All procurements of goods, works and services financed by the Fund will comply with ADF procurement rules of procedure and be based on appropriate standard Bank bidding documents. The procurement procedures are summarized in Table 5.2 below.

Table 5.2: Procurement Arrangements (in UA million)

International National Short Government

EXPENDITURE CATEGORIES Comp. Bidding Comp. Bidding Others List Financing Total 1. Civil Engineering Works 1.1 - Construction of HCs 1.23 [1.074] 0.156 1.23 [1.07] 1.2 - Rehabilitation of hospitals 2.84 [2,48] 0.359 2.84 [2.48] 1.3 - Improvement of training centres 0.19 [0.17] 0.024 0.19 [0.17] 1.4 - Construction PIU 0.04 [0.037] 0.002 0.04 [0.037] Sub-total const/rehab. 4.30 [3.76] 2. Goods 2.1 - Equipment of hosp/HC/ONSP/Maint 2.22 [2.22] 2.22 [2.22] 2.2 - Furniture for hospitals and HCs 0.12 0.12 2.3 - Vehicles and motorcycles 0.22 [0.22]* 0.22 [0.22] 2.4 - Equipment PIU 0.09 [0.9] 0.09 [0.09] Sub-total Equipment/Supplies 2.65 [2,54] 3. Consultancy Services 3.1 - Studies and supervision 0.38 [0.38] 0.380 [0.380] 3.2 - KAP Studies/surveys 0.17 [0.17] 0.17 [0.17] 3.2 - Training/sensitization 0.69 [0.622] 0.07 0.69 [0.62] 3.3 - Technical Assistance 0.45 [0.45] 0.45 [0.45] 3.4 - Audit 0.05 [0.05] 0.05 [0.05] Sub-total Consultancy Services. 1.73 [1.67] 4. Miscellaneous 4.1 Operating costs 0.42 [0.10]** 0.32 0.46 [0.10] Sub-total misc. 0.42 [0.10] Total Project Cost 5.06 [4.71] 1.55 [1.37] 0.64 [0.32] 1.73 [1.667] 1.05 9.10 [8.05] [..] : Portion financed by ADF Others : * Private agreement with IAPSO ICB : International Competitive Bidding ** National shopping NCB : National Competitive Bidding

5.4.2 Civil engineering works: (i) ICB for rehabilitation works of district hospitals and NCB for the construction of health centres. 5.4.3 Goods: (i) ICB for the procurement of specialized equipment/furniture and supplies (pharmaceutical drugs and consumables; office consumables) of hospitals, HCs and the ONSP; (ii) IAPSO for all vehicles and motorcycles to be procured under the project, (iii) NCB for the furniture of structures established; and (iv) national shopping for the procurement of equipment and furniture as well as office supplies, consumables, fuel and maintenance of PIU vehicles, in view of the small contract amount and the existence of enough local suppliers to guarantee competitive prices. 5.4.4 Consultancy Services: (i) Invitation to bid on the basis of a short list for the recruitment of a consulting firm to conduct further engineering studies, update BDs for the civil engineering works, supervise and monitor the procurement of equipment and furniture, and supervise the construction/rehabilitation works; (ii) specialized training institutions abroad will be recruited on the basis of a short list; (iii) local seminars will be conducted by national experts recruited through local invitation for applications; (iv) technical assistants, who will be responsible for the establishment of the different structures, will be recruited on the basis of a

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short list ; the same will apply to the auditing firm to audit project accounts; (v) the health structures will be revitalized by NGOs to be selected on the basis of a short list with the support of UNICEF and GTZ; (vi) in view of the importance of cultural aspects and the small contract amounts, the studies and surveys will be conducted by local agencies recruited on the basis of a short list. 5.4.5 General Procurement Notice (GPN): The text of the GPN will be adopted with the Borrower at the time of negotiations and will be communicated to the Bank for publication in “Development Business” upon approval of the loan proposal by the Board of Directors. 5.4.6 Review Procedures: The following documents will be submitted to the Bank for review and approval before publication: • specific procurement notice; • short lists and letters of invitations to bid; • bidding documents; • bid evaluation report including recommendations on contract awards ; and • draft contracts, if those in the bidding documents have been modified. 5.5 Disbursements

Given that the disbursement rate is a performance indicator of project

management, arrangements will be made to ensure availability of project resources and transparency in their use. The PIU will be responsible for verifying if the services by suppliers comply with the project specifications, and will prepare disbursement requests to be submitted to the Inspector General of Health for endorsement before transmission to the CAA or ADF. The requests should be for at least UA 20 000 for payments from ADF funds. Two separate special accounts will be opened: one to receive the ADF funds for project management, and the other to receive the Government’s counterpart contributions. Bills to be paid from the counterpart contributions will be processed directly by the PIU and CPP before transmission to the CAA for payment. 5.6 Monitoring and Evaluation The PIU will, under the supervision of the CPP, be responsible for monitoring, managing and supervising all project activities. It will also submit to ADF, in compliance with the format in force, quarterly reports on the status of the project within 30 days following the end of each quarter. The Chairperson of the CPP will monitor project activities through periodic meetings with the PIU team. At project completion, the PIU will prepare and submit a completion report, in compliance with the format recommended by the Bank. The audit reports will be regularly submitted to ADF for review within six months following the end of each fiscal year. As for the Bank Group, it will undertake a project launching mission, and supervision missions at least once a year as well as a mid-term review mission. 5.7 Project Accounting and Audit

The PIU will keep project accounts in accordance with the provisions of the Bank’s manual “Guidelines for the preparation of financial reports and review of project accounts”. To that end, it will keep complete registers showing expenditure by component, expenditure category and source of finance as well as separate accounts for all Bank-financed operations. Project accounts will be audited yearly by an external audit firm; the audit will be financed from ADF resources.

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5.8 Coordination of Aid The coordination of aid is fairly well organized, particularly in cooperation institutions which organize periodic meetings with health donors to discuss their operations and prospects in order to coordinate their activities. They also discuss their various strategies for the country and those of the country so as to harmonize them. The Government contributes to the coordination by strengthening the Cooperation Division responsible for monitoring projects and relations with the donors. Periodic meetings are organized between this Division and the donors. 6. PROJECT SUSTAINABILITY AND RISKS 6.1 Recurrent Costs The recurrent expenditure resulting from the project is not significant. They are shared between the maintenance costs of health units and equipment, as well as recurrent expenses and staff salaries of new HCs. The entire staff of the ONSP will be taken from the staff of the CNDS and MINHEALTH. These recurrent expenses amount to CFAF 138.208 million and account for 0.4% of the recurrent budget of MINSANTE (CFAF 30. 599 billion) for the 1998/1999 fiscal year. The expenses are not high, and can therefore be borne by the State. 6.2 Project Sustainability and Cost Recovery 6.2.1 The cost recovery system was put in place with the initiation of REOSSP in 1990 and entails payment for medical treatment and the sale of drugs. The proceeds are used in revitalizing health structures by motivating staff, replacing drugs, maintaining the premises and equipment, and supporting some community activities. The objectives of the system are: (i) accessibility of PHC for the entire population through a policy of decentralization of management in the HDs; and (ii) inclusion of all PHC activities in the HC and further empowering of the community by involving them in the financing and management of health services. Several legal instruments have been issued for that purpose by the Government, in particular: (i) the law of 1990 on the freedom of association; (ii) the law of 1992 authorizing health units to keep 50% of their income for recurrent expenditure; (iii) the decree of 1993 defining the terms and conditions for managing resources allocated to public health units and governing the establishment of committees to manage the income of these units; and (iv) the law of 1 July 1998 authorizing health units to keep all their income. The last three instruments show the Government’s desire to decentralize the management of resources in the system. 6.2.2 A resource co-management system was introduced for health structures with the participation of the community in all the stages of the management cycle of health structures, in particular the planning, implementation, monitoring and evaluation of activities. This partnership was organized in the form of an organization chart comprising the State and community structures, commonly referred to as dialogue structures, at all levels of the health pyramid. For example, there are: (i) a Special Health Promotion Fund (FSPS) in each Provincial Delegation; (ii) management committees for each province (COGEPRO), district (COGEDI), health area (COGE) and DH (COGEH); and (iii) health committees for each district (COSADI), and health area (COSA). However, it should be pointed out that this system does not work systematically in all the provinces; some are more advanced while others are behind, as is the case with the Centre and the South.

25

6.2.3 The project will try to revitalize or establish dialogue structures around project health units. Their members will receive training with the assistance of NGOs, which will enable them to ensure social mobilization through sensitization, information and sanitation activities. They will participate in the management of financial, human and material resources of project health structures and surrounding areas. The staff of these organs will be 50% women and 50% men. 6.2.4 As for project sustainability, it will be ensured by the following factors: (i) inclusion of the SNIS in the health system; consequently, the preparation of reports on health statistics will be an integral part of the routine activities of health units; (ii) the results of the national study on maintenance will be the subject of broad consultation and consensus at the national level, hence it would be easy to implement its recommendations; (iii) the training of maintenance employees of both the public and private sectors at the provincial level will standardize knowledge and practices in maintenance within the province and contribute to the sustainability of the activities; (iv) the strengthening of health services of the project through construction/rehabilitation works, equipment and revitalization activities for the said services, will give fresh impetus to the development of participation by the population in health activities, which is an unavoidable condition for their ownership of the project. 6.3 Major Risks and Mitigation Measures 6.3.1 One of the major risks of the project is the persistence of the economic crisis in the country. This risk is also linked to that of non-payment of budget allocations to the project health structures by the Government. The country’s recent economic performance, as well as the political desire to control public expenditure and the efforts to rationalize the health system, will contribute to reducing these risks and ensuring the success of the project. 6.3.2 Taking into account the delays in the conduct of the pre-investment study and the World Bank project, MINHEALTH’s capacity for implementing the project within schedule is low. The system for recruiting senior PIU staff and the institutional strengthening of MSP structures involved in the project implementation will reduce this risk. 6.3.3 Staff demotivation following the reduction of salaries by 50% in the Public Service is also a risk for the project. The training of health staff as proposed in the project and the supply of efficient working tools will contribute to motivating them. 6.3.4 Continuation of the SNIS at the intermediate and central levels is a necessary condition for establishing the ONSP. The encouraging results of the establishment of the system, which is already operational at the peripheral level, and the programming of phase II of the SNIS project for the current year augurs positive development of the system. The project proposes activities to give fresh impetus to the implementation of the SNIS. 6.3.5 Acceptance of the project objectives by the population is a condition for its success. Revitalization activities for the HDs and the training of members of dialogue structures will contribute to maintaining the population’s interest in the project activities. 7. PROJECT BENEFITS 7.1 Economic Analysis 7.1.1 In view of the country’s health profile, it is obvious that the project has the potential of generating substantial economic gain - it will increase productivity and the

26

productive potential. In fact, the series of training activities in maintenance as proposed in the project will solve the thorny problem of non-operation of 75% of the biomedical equipment in health structures, which impacts greatly on the quality of health services. The maintenance expenses which health units currently pay could be reduced with the establishment of a rational system for managing maintenance problems by involving private enterprises through subcontracting, which has the advantage of reducing fixed recurrent expenses. The savings thus made could be used for other types of expenses, which are economically beneficial for the health structures, in particular drugs and minor equipment, which will contribute to improving the quality of services. Furthermore, by extending the life of biomedical equipment, the improvement of maintenance services will reduce expenditure in foreign exchange for the replacement of the equipment, and make the funds available for other uses.

7.1.2 The construction/rehabilitation of health structures will enable them to meet the expectations of the population, and consequently increase the patient attendance rates of health units. It will necessarily lead to an increase in income, which will contribute to ensuring the financial autonomy of health units. The good services offered to the population by the project health units, coupled with the availability of competent staff and an efficient technical support centre will reduce disease-related constraints particularly work days lost and health expenses which could be used for economic activities. Furthermore, the time taken by the population to travel to the new HCs will be reduced, and the gained time will be used for income-generating activities. Private enterprises employing the population will witness a reduction in the number of days granted for sick leave and their productivity will improve because of the availability of more abundant labour. 7.1.3 Development of community participation and outreach activities by the communities themselves, sensitization on health problems and their prevention will enable the population to better understand how some diseases are contracted and how to prevent them. It will allow for transparent management of the resources of the health facilities, which will be used more rationally. 7.2 Analysis of Social Impact

Impact on Women 7.2.1 The project will have a positive impact primarily on women and children with the objective of reducing general mortality and morbidity by 20% in 2008 because they are the main beneficiaries of the project. The 20% increase in the intake capacity of health structures in the project areas, coupled with the improved quality of health care services offered by the network of health facilities established or rehabilitated will very significantly reduce maternal and infant mortality rates. Prenatal monitoring of pregnant women will be improved and this will allow for better management of high-risk pregnancies. The patient attendance rates of the health structures will increase, because childbirths at home are still common especially in rural areas due to the lack of qualified and motivated staff and equipment. Staff training and equipment of project health structures will increase staff motivation and the quality of services. 7.2.2 Control of fertility by women, through the services and IEC activities as regards reproductive health, will also have an impact on the health of women and children. It will enable women to devote less time to maternity and childcare; such time could be used for income-generating activities. These activities will enable women to be economically independent, and this will contribute to improving their social status. 7.2.3 Women will be empowered within dialogue structures in which women/men parity will be respected; they will therefore ensure that their specific health needs are taken into

27

account within structures for which they will be responsible. Out of the 84 members of dialogue structures who will receive training, 42 will be women. Such participation will contribute to improving the services through better communication between the service providers and the customers most of whom are women. Women will be recognized as partners in the development of health by the public authorities, community leaders and the population, and this will improve their status.

Impact on Poverty

7.2.4 The project will have a direct positive impact on poverty reduction: (i) by improving health care, it will enable vulnerable categories to have access to health services under the best conditions; (ii) by contributing to the general improvement of the health conditions of the population in the country, it will reduce the portion of their income hitherto used for health care and consequently improve their living conditions; (iii) by contributing to the general improvement of the health conditions of the population, it enables them to increase their productivity and devote more time to economic activities. 7.2.5 Specifically, the 20% reduction in the mortality and morbidity rates will benefit the most underprivileged population, particularly people in rural areas who record higher rates than those in urban areas. The establishment of new health structures and the rehabilitation of existing structures in disadvantaged areas will contribute to increasing the intake capacity of health units by 20% and will thereby enhance equal access to basic facilities, particularly among the poor. The poor will suffer less severe cases of illness, which will be treated fairly early. This will enable them to save on health expenses because severe cases are treated. 7.2.6 The jobs created during the construction/rehabilitation works will contribute directly to additional income, and consequently poverty reduction in the area. These impacts will be assessed by KAP surveys at project start-up and completion. 8. CONCLUSIONS AND RECOMMENDATIONS 8.1 Conclusions The project contributes to the achievement of the objectives of the REOSSP Policy in Cameroon and meets a real need of the population. It is fully consistent with the Bank’s health policy and falls in line with an overall plan for the strengthening of health services adopted by the donor community. The establishment or rehabilitation of health structures in disadvantaged areas, coupled with the development of support structures such as the SNIS and the ONSP, and the training units/modules for biomedical maintenance, will necessarily contribute to the improvement of the health conditions of the population. 8.2. Recommendations and Loan Approval Conditions

In view of the foregoing, it is recommended that a loan not exceeding UA 8.05 million be granted to the Republic of Cameroon, for the implementation of the project. The loan will be subject to the general conditions and the following special conditions: A. Conditions Precedent to Effectiveness of the ADF Loan Effectiveness of the loan will be subject to the fulfilment, by the Borrower, of the conditions stipulated in Section 5.01 of the General Conditions. B. Conditions Precedent to the First Disbursement

28

The obligations of the Fund to make the first disbursement from the loan resources will be subject to the effectiveness of the Loan Agreement and fulfilment of the following conditions by the Borrower: i) Provide the Fund with evidence of the establishment of a Project Steering Committee

comprising a representative each from the following ministries and agencies: MINHEALTH, MINPAT, MINEFI, MINTP, the European Union, GTZ, the health services of the Catholic Church and Coalition of NGOs, as well as the appointment of its members (paragraph 5.2.1);

ii) Provide the Fund with evidence of the establishment of the PIU, the appointment of the

panel members responsible for the recruitment of PIU senior staff ; the list of the shortlisted candidates should be submitted to ADF for approval (paragraph 5.1);

iii) Provide the Fund with evidence of the allocation of functional office premises to the PIU

(paragraph 5.1) ; iv) Provide the Fund with evidence of the recruitment of staff as provided for and mentioned

in the appraisal report, as well as the recruitment of support staff comprising two secretaries, three drivers, a messenger and a security guard (paragraph 5.1);

v) Provide the Fund with evidence of having opened two (2) separate accounts in a

commercial bank in the name of the project into which will be deposited ADF resources and the Government’s counterpart contributions respectively (paragraph 5.2.4).

C. Other Conditions The borrower shall also: i) Communicate to the Fund, not later than 30 June 2002, the report on the national study

on the maintenance of biomedical equipment (paragraphs 4.6.16 and 4.6.18) ii) Adopt, not later than 31 December 2002, a national biomedical equipment maintenance

policy (paragraph 4.6.18) ; iii) Provide the Fund with evidence, not later than 30 June 2002, of having allocated

functional office premises to the National Public Health Observatory (ONSP) (paragraph 4.2.6);

iv) Submit to the Fund for approval, within six (6) months following the signing of the Loan

Agreement, a training programme indicating the names, qualifications and/or experience of candidates for study grants, including useful information on the training centres (paragraph 4.6.9);

v) Transmit to the Fund, before their departure for training, the individual undertakings,

signed by each of the beneficiaries of the academic training, to work in the services for which they are being trained for a minimum period of l5 years (paragraph 4.6.9);

vi) Provide the Fund with evidence, not later than 31 December 2002, of having transferred

the required staff to the ONSP and Health Centres to be constructed (paragraph 3.2.5); and

vii) Pay 50% of the Government’s annual counterpart contributions into the appropriate

29

account within 30 days after the end of each semester, in accordance with financing schedule (paragraphs 4.9.1 and 5.2.4).

ANNEX 1 CAMEROON: HEALTH SYSTEM DEVELOPMENT PROJECT

ANNEX II

Organization Chart of the Ministry of Health

SecretariatDrivers, Messenger,

Security Guard

Civil Engineer Biomedical Engineer Accountant

Director PIU

Inspector General Private Secretary

First Technical Adviser Communication Service

Second Technical Adviser Accountant

Studies, Planning of Health Informationand Computer Services Division

Cooperation Division

Monitoring Service Legal Services

Mail and Liaison Service Translation Service

Documentationand Records Service

Department ofHuman Resources

Department ofFinancial Resources and Infrastructure

Department ofHospital Medicine

Department of Pharmacyand Medicine

Department ofCommunity Health

Secretary-General

Minister of Health

ANNEX III

ANNEX IV

CAMEROON: HEALTH SYSTEM DEVELOPMENT PROJECT DETAILED EXPENDITURE CATEGORIES TABLE

In CFAF million In UA million Source of Finance

in UA million EXPENDITURE CATEGORIES

F.E. L.C. Total F.E. L.C. Total ADF GVT

Civil Engineering Works - Const./rehab. of HCs 698.25 299.25 997.50 0.78 0.33 1.11 0.97 0.14 - Const./rehab. (hospitals) 1,555.58 666.68 2,222.26 1.74 0.74 2.48 2.17 0.31- Development of Training Centres 105.00 45.00 150.00 0.12 0.05 0.17 0.15 0.02- Construction of PIU 21.88 9.38 31.25 0.02 0.01 0.03 0.03 0.00Goods - Equipment of hosp. and HCs 1,556.55 0.00 1,556.55 1.74 0.00 1.74 1.74 0.00- Furniture for hosp. and HCs 0.00 95.87 95.87 0.00 0.11 0.11 0.00 0.11- Equip. ONSP 87.91 0.00 87.91 0.10 0.00 0.10 0.10 0.00 Maintenance equipment 163.40 0.00 163.40 0.18 0.00 0.18 0.18 0.00- Vehicles and motorcycles 185.00 0.00 185.00 0.21 0.00 0.21 0.21 0.00 - Equipment PIU 75.20 0.00 75.20 0.08 0.00 0.08 0.08 0.00Consultancy services -Studies and supervision 284.38 31.60 315.98 0.32 0.04 0.35 0.35 0.00- Studies PSC 126.02 14.00 140.02 0.14 0.02 0.16 0.16 0.00 - Training/sensitization 362.12 194.99 557.10 0.40 0.22 0.62 0.56 0.06 - Technical Assistance 333.45 37.05 370.50 0.37 0.04 0.41 0.41 0.00 - Audit 36.90 4.10 41.00 0.04 0.00 0.05 0.05 0.00Miscellaneous Operating costs 67.64 270.56 338.20 0.08 0.30 0.38 0.09 0.29 Total base cost 5,657.77 1,669.97 7,327.74 6.32 1.86 8.19 7.25 0.93Contingencies and inflation 596.19 221.92 818.11 0.67 0.25 0.91 0.80 0.11Total cost 6,253.96 1,891.89 8,145.85 6.99 2.11 9.10 8.05 1.05

ANNEX V

Page 1 of 3REPUBLIC OF CAMEROUN

DEVELOPMENT OF HEALTH SERVICES DETAILED BASE COSTS

COMPONENT I: UPGRADING OF HEALTH INFRASTRUCTURE Quantity U.P. Total Total

A. Studies and Supervision CFAF thousand CFAF million UA thousand (Lump sum for construction /rehabilitation costs)

Endengue HC Study and supervision Endengue HC (8%) 1 13.100.0 13.10 14.63 Study and supervision Sangmelima 1 HC (8%) 1 13.100.0 13.10 14.63 Study and supervision Sangmelima 2 HC (8%) 1 13.100.0 13.10 14.63 Study and supervision N'Golbang HC (8%) 1 13.100.0 13.10 14.63 Study and supervision Amvom HC (8%) 1 13.100.0 13.10 14.63 Study and supervision Akom HC (8%) 1 13.100.0 13.10 14.63 Sub-total HCs 78.60 87.81 Study and supervision Ayos Hospital (8%) 1 143.500.0 143.50 160.31 Study and supervision Obala Hospital (8%) 1 10.290.0 10.29 11.50 Study and supervision N'Gog Maputi Hospital (8%) 1 23.590.0 23.90 26.35 Sub-total Hospitals 177.38 198.15 KAP Survey (at project start-up and completion) 2 20,000 40.00 44.68

Sub-Total Category A. Studies and Supervision (Base cost) 295.98 330.64 Quantity U.P. Total Total

B. Construction / Rehabilitation CFAF thousand CFAF million UA million 1.1 Construction (Net gross. area)

1. Endengue HC 655.00m² 250 /m² 163.75 182.932 Sangmelima 1 HC 655.00m² 250 /m² 163.75 182.933 Sangmelima 2 HC 655.00m² 250 /m² 163.75 182.934 Ngolbang HC 655.00m² 250 /m² 163.75 182.935 Amvom HC 655.00m² 250 /m² 163.75 182.936 Akom HC 655.00m² 250 /m² 163.75 182.937 Development of maintenance premises (lump sum) 6 x 2,500.00 15.00 16.76

Sub-Total Category B. Construction 3,936.0m² 253 /m² 997.50 1,114.32 1.2 Rehabilitation/Extension

1 Ayos Hospital Construction 3,585.00m² 250 /m² 896.25 1.001.21 Rehabilitation 5,100.00m² 175 /m² 892.50 997.02 Development of maintenance premises (lump sum) 2 x 2,500.00 5.00 5.59 Sub-total 1,793.75 2,003.82

2 Obala Hospital Rehabilitation 735.00m² 175 /m² 128.63 143.69 Development of maintenance premises (lump sum) 1 x 2,500.00 2.50 2.79 Sub-total 131.13 146.49

3 N'Gog Mapudi Hospital Rehabilitation 1,685.00m² 175 /m² 294.88 329.41 Development of maintenance premises (lump sum) 1 x 2,500.00 2.50 002.79 Sub-total 297.38 332.21 Sub-Total Category B. Rehabilitation 11,178.0m² 200 /m² 2,237.50 2,499.54

Sub-Total Category B. Construction / Rehabilitation (Base cost) 3,219.76 3,596.83

C. Equipment /Supplies 1 For 1 HC

* Biomedical equipment 1 x 50,000.00 50.00 55.86 * Office supplies 1 x 17,750.00 17.75 19.83 * Furniture 1 x 3,500.00 3.50 3.91 *Motorcy 1 x 2,500.00 2.50 2.79 * Computer equipment 1 x 1,500.00 1.50 1.68 Sub-total 1 HC 75.25 84.06 For the 6 HCs Sub-total 6 HCs 6 x 75,250.00 451.50 504.38

7 Ayos Hospital

* Biomedical equipment 1 x 440,000.00 440.00 491.53 * Office supplies 1 x 79,754.00 79.75 89.09 * Furniture 1 x 45,940.00 45.94 51.32 * Computer equipment 1 x 5,000.00 5.00 5.59 * Ambulance 2 x 25,000.00 50.00 55.86 Sub-total 620.69 693.38

8 Obala Hospital * Biomedical equipment 1 x 180,000.00 180.00 201.08 * Office supplies 1 x 13,683.00 13.68 15.28 * Furniture 1 x 9,096.00 9.10 10.17 * Computer equipment 1 x 5,000.00 5.00 5.59 * Ambulance 1 x 25,000.00 25.00 27.93 Sub-total 232.78 260.04

9 N'Gog Mapudi Hospital * Biomedical equipment 1 x 220,000.00 220.00 245.76 * Office supplies 1 x 36,659.00 36.66 40.95 * Furniture 1 x 19,834.00 19.83 22.15 * Computer equipment 1 x 5,000.00 5.00 5.59 * Ambulance 1 x 25,000.00 25.00 27.93 Sub-total 306.49 342.38 Sub-total Biomed. equip. /Supplies HC & Hosp. 1,159.96 1,295.81 C. IEC equipment & maintenance * For the HCs 6 x 5,045.00 30.27 33.81 * Strengthening NHMIS/GIS/d for the HCs 6 x 150.00 0.90 1.01 * For the hospitals 3 x 4,669.50 14.01 15.65 * Initial supply of essntial drugs/equipment 3 x 25,740.00 77.22 86.26 * Initial supply of management tool 3 x 1,188.00 3.56 3.98 * Maintenance equipment (HC) 6 x 3,000.00 18.00 20.11 * Maintenance equipment (Hosp.) 3 x 4,000.00 12.00 13.41 Sub-total IEC equip. 155.96 174.22

Sub-Total Category C.Equipment /Supplies. 1,767.42 1,974.41

ANNEXE V Page 2 of 3

Quantity U.P. Total Total D. Training CFAF thousand CFAF million UA thousand

* IEC in HCs 12 x 257.40 3.09 3.45 * IEC in Hospitals 1 x 4,965.90 4.97 5.55 * Microplanning in HCs 6 x 118.80 0.71 0.79 * Training/refresher courses for HC staff 1 x 9,767.76 9.77 10.91 * Training/refresher courses for Hospital staff. 1 x 4,257.00 4.26 4.76 * Monitoring in HCs 12 x 273.90 3.29 3.68 * Monitoring in Hospitals. 1 x 6,772.90 6.77 7.56 *Support for Monitoring 1 x 4,990.00 4.99 5.57 * Maintenance training for HC staff 1 x 7,500.00 7.50 8.38 * Maintenance training for Hospital staff. 1 x 7,500.00 7.50 8.38

Sub-Total Category E.Training (Base cost) 52.85 59.04

TOTAL BASE COST OF COMPONENT I 5,356.01 5,983.27

TOTAL COST OF COMPONENT I (incl. contingencies and inflation) 5,983.82 6,684.60

COMPONENT II: ESTABLISHMENT OF A HEALTH OBSERVATORY Quantity U.P. Total Total

A. Studies and Supervision CFAF thousand CFAF million UA thousand * Study on the Communication System (lump sum) 1 40,000.00 40.00 44.68 * Survey on perceptions (lump sum) 2 50,000.00 100.00 111.71 * Evaluation of the Observatory (lump sum) 1 20.00 0.02 0.02

Sub-Total Category A. Studies and Supervision (Base cost) 140.02 156.42

C. Equipment /Supplies * Office automation software (AT) 1 x 2,500.00 2.50 2.79 * Laser printer (AT) 2 x 700.00 1.40 1.56 * Microcomputers PC (AT). 1 x 2,500.00 2.50 2.79 * UPS 1 x 700.00 0.70 0.78 * High speed Laser printer (DESI-CIS) 1 x 700.00 0.70 0.78 * Micro-computers PC (DESI-CIS) 1 x 2,500.00 2.50 2.79 * UPS (DESI-CIS) 1 x 700.00 0.70 0.78 * Modem 1 x 300.00 0.30 0.34 * Roll plotting board (DESI-CIS) 1 x 5,000.00 5.00 5.59 * Management software 1 x 1.00 1.00 1.12 * NHMIS development software (DESI-CIS) 1 x 6.00 6.00 6.70 * Cartography software (DESI-CIS) 1 x 2.00 2.00 2.23 * Microcomputers PC (Provinces). 4 x 2,500.00 10.00 11.17 * Colour laser printer (Provinces) 4 x 700.00 2.80 3.13 * UPS (Provinces) 4 x 700.00 2.80 3.13 * Modem (Provinces) 4 x 300.00 1.20 1.34 * MS-Office software (Provinces) 4 x .00 2.00 2.23 * Microcomputers PC (Districts). 8 x 2,500.00 20.00 22.34 * Colour laser printer (Districts) 8 x 700.00 5.60 6.26 * UPS (Districts) 8 x 700.00 5.60 6.26 * MS-Office software (Districts) 8 x 500.00 4.00 4.47 * Telephone/fax 8 x 500 4.00 4.47 * Photocopier 1 x 2,000.00 2.00 2.23 * Vehicle 4x4 1 x 20,000.00 20.00 22.34 * Furniture (lump sum) 1 x 2,609.00 2.61 2.92

Sub-Total Category C.Equipment Supplies. (Base cost) 107.91 120.55

D. Training * Sensitization Seminar on the SNIS (lump sum) 1 10,000.00 10.00 11.17 * Training of trainers (Provinces/lump sum) 1 3,000.00 3.00 3.35 * Training of trainers (Districts/lump sum) 1 3,000.00 3.00 3.35 * Training/local refresher course information technology 1 3,000.00 3.00 3.35 * Training/local refresher course in HIS/b 1 3,000.00 3.00 3.35 * ST training of Chief Medical Officers of Districts 8 8,000.00 64.00 71.50 * LT training of senior staff HI 2 15,000.00 30.00 33.51 * LT training in Public Health (Epidemiology) 1 22,000.00 22.00 24.58 * Field trips (NHMIS officials) 1 3,000.00 3.00 03.35 * Field trips (ONSP Dir, HIS official MINHEALTH, Epidemio) 3 3,000.00 9.00 10.05 * ConsensusWorkshop (Finalization NHMIS concept) 1 9,000.00 9.00 10.05 * Consensus Workshop Dev. Indicators (Provinces) 1 2,000.00 2.00 2.23 * Consensus Workshop Dev. Indicators (National) 1 5,000.00 5.00 5.59

Sub-Total Category E.Training (Base cost) 166.00 185.44

E.. Technical Assistance * 1 Health Information Expert (inter.(all inclusive) 1 x 24 P/month 7.000,00 168.00 187.67 * Computer Expert (inter.) (all inclusive) 1 x 12 P/month 7.500,00 90.00 100.54 * Communication Expert (inter.) (all inclusive) 1 x 6 P/month 7.500,00 45.00 50.27

Sub-Total Category F. Technical Assistance (Base cost) 303.00 338.49

TOTAL BASE COST OF COMPONENT II 716.93 800.89TOTAL COST OF COMPONENT II (incl. contingencies and inflation) 780.10 871.46

COMPONENT III: SUPPORT FOR MAINTENANCE OF BIOMEDICAL EQUIPMENT

Quantity U.P. Total Total B. Construction / Rehabilitation CFAF thousand CFAF million UA million

Development of premises of 3 Training Centres (200m2 x 3) 600,00m² 250 /m² 150.00 167.57

Sub-Total Category B. Construction / Rehabilitation (Base cost) 150.00 167.57

C. Equipment /Supplies * Equipment of 3 Training Centres 3 x 50,000,00 150.00 167.57 * Spare parts 1 x 5,000,00 5.00 5.59 * Tool kit for Training workshop for maintenance workers 84 x 100,00 8.40 9.38

* Motorcycles for the SNIS (2 for each of the 10 provinces) 20 x 2,500,00 50.00 55.86

Sub-Total Category C. Equipment /Supplies (Base cost) 213.40 238.39ANNEX V

Page 3 of 3D. Training

* Training of maintenance trainers 9 22,000.00 198.00 221.19 * Training workshop for maintenance workers 3 x 19,700.00 59.10 66.02 * (Provincial) Consensus workshop on the results of the study 10 x 1,215.00 12.15 13.57 * (National) Consensus workshop on the results of the study 1 x 3,000.00 3.00 3.35 * Training of biomedical technicians (long course) 3 x 22,000.00 66.00 73.73

Sub-Total Category E. Training (Base cost) 338.25 377.86

TOTAL BASE COST OF COMPONENTIII 701.65 783.82TOTAL COST OF COMPONENT III (incl. contingencies and inflation) 773.80 864.42

COMPONENT IV: PROJECT MANAGEMENT

Quantity U.P. Total Total B. Construction / Rehabilitation CFAF thousand CFAF million UA thousand

Rehabilitation of PIU premises 125.00m² 250 /m² 31.25 34.91

Sub-Total Category B. Construction / Rehabilitation (Base cost) 31.25 34.91

C. Equipment /Supplies

Equipment - Computer equipment

* Telephone fax 1 x 500.00 0.50 0.56 * Photocopier 1 x 1,000.00 1.00 1.12 * Micro-computer PC (AT) 3 x 2,500.00 7.50 8.38 * Network laser printer (PIU) 1 x 1,000.00 1.00 1.12 * UPS 1 x 700.00 0.70 0.78 * Office automation network software 1 x 2,000.00 2.00 2.23 * Accounting management software off. Automation network 1 x 1,000.00 1.00 1.12 * Sundry software 1 x 1,500.00 1.50 1.68 * Vehicles 4x4 1 x 20,000.00 20.00 22.34 * Saloon car 2 x 10,000.00 20.00 22.34 * Furniture (lump sum) 20.00 22.34

Sub-Total Category C.Equipment /Supplies. (Base cost) 75.20 84.01

E.. Technical Assistance * Information Technology expert 3 P/month 7,500.00 22.50 25.14 * Consultant à la carte 6 P/month 7,500.00 45.00 50.27

Sub-Total Category F. Technical Assistance (Base cost) 67.50 75.41

F. Operating Costs Administration

* Office supplies 4 years 2,750.00 11.00 12.29 Telephone, electricity, fax, E-mail 4 years 3,000.00 12.00 13.41 Mail 4 years 2,000.00 8.00 8.94 Publication of invitations to bid 3,000.00 3.00 3.35 Sub-total 34.00 37.98

Maintenance of Rolling Stock Fuel and lubricant (1 PIU vehicles) 1 x 4 years 1,500.00 6.00 6.70 Fuel and lubricants (2 AST vehicles) 2 x 2 years 1,500.00 6.00 6.70 Insurance 3 x 4 years 1,500.00 18.00 20.11 Maintenance of vehicles 3 x 4 years 1,000.00 12.00 13.41 Sub-total 42.00 46.92

Mission and Travel Expenses * Mission expenses to the Bank headquarters for 2 persons of the PIU, for 2 missions per year (2 x 2 = 4) 4 x 4 years 2,500.00 40.00 44.68 * Travel expenses for our 2 person of the PIU, 10 days per month for 3 years (2 x 10 x 12 = 240) 240 days for 3 years 50.00 36.00 40.22 * Meetings of the Steering Committee/PIU (4 meetings/year x 4 years) 4 x 4 years 500.00 8.00 8.94 * Mid-term review: visit of the project sites for 3 persons (lump sum) 1,500.00 1.50 1.68 * Completion: visit of the project sites for 3 persons (lump sum) 1,500.00 1.50 1.68 Sub-total 87.00 97.19

PIU Staff Salaries Project Manager 1 x 48 months 750.00 36.00 40.22 Civil Engineers 1 x 48 months 600.00 28.80 32.17 Biomedical Engineers 1 x 48 months 600.00 28.80 32.17 Accountant 1 x 48 months 500.00 24.00 26.81 Secretaries 2 x 48 months 300.00 28.80 32.17 Drivers 3 x 48 months 150.00 21.60 24.13 Messengers

1 x 48 months 80.00 3.84 4.29

Sec. Guards

1 x 48 months 70.00 3.36 3.75

Sub-total 175.20 195.72

Sub-Total Category G. Operating costs (Base cost) 338.20 377.81

G. Audit Audit of project accounts

Mission to set up the accounting plan 1 x 1 year 7,000.00 7.00 7.82 1 mission per year 1 x 4 years 7,000.00 28.00 31.28 Trips per year 1 x 4 years 1,500.00 6.00 6.70

Sub-Total Category H. Audit (Base cost) 41.00 45.80

TOTAL BASE COST OF COMPONENT IV 553.15 617.93TOTAL COST OF COMPONENT IV (incl. contingencies and inflation) 608.13 679.35

TOTAL BASE COST OF THE PROJECT: COMPONENTS I+II+III+IV 7.327.74 8,185.9

TOTAL PROJECT COST (incl. contingencies and inflation) 8.145.85 9.099,83

ANNEX VI

LIST OF ANNEXES TO THE PROJECT IMPLEMENTATION DOCUMENT No. of pages 1. ONSP ORGANIZATION CHART 1 2. TERMS OF REFERENCE OF THE PIU 2 3. TERMS OF REFERENCE OF SHORT AND

MEDIUM-TERM CONSULTANTS 3 4. SUMMARY TOR FOR CONSULTING FIRM RESPONSIBLE

FOR WORKS SUPERVISION AND MONITORING 1 5. SUMMARY TERMS OF REFERENCE FOR STUDIES

AND SURVEYS 4 6. DETAILED PROJECT COSTS 16 7. STANDARD PROTOCOL OF AGREEMENT BETWEEN THE

PROJECT AND NGOs RESPONSIBLE FOR DEVELOPING HEALTH STRUCTURES 3

8. DETAILED PLAN OF DEVELOPMENT ACTIVITIES

FOR HEALTH STRUCTURES 9 9. DETAILED TABLE OF RECURRENT COSTS 1

Annex

CORRIGENDUM

REPUBLIC OF CAMEROON HEALTH SYSTEM DEVELOPMENT PROJECT

Modifications and a few minor changes have been made to the Appraisal Report as follows: 1. Page ii, ACRONYMS AND ABBREVIATIONS :

MINEFI:

Instead of: Ministry of Finance, Read: Ministry of the Economy and Finance;

MINPAT :

Instead of: Ministry of Investments, Property and Territorial Development; Read: Ministry of Public Investments and Territorial Development;

2. Page vi, Project Matrix, Project Objective, point 1.1 : Instead of: 20% increase in the intake capacity of health units in the Centre and South Provinces…; Read: 20% increase in the intake capacity of health units in the target districts…; 3. Page 1, § 1.2, last sentence:

Add the 4th objective of the PNDS: “(iv) to organize the management of epidemics, emergencies and disasters”;

4. Page 20, § 5.2.1 : Instead of: …the Steering Committee comprising a representative from each of the

following ministries and agencies: MINHEALTH, MINPAT, MINEFI, MINTP, the European Union, GTZ, the health services of the Protestant Church and the Coalition of NGOs.

Read: …the Project Steering Committee (CPP) comprising 5 representatives from

MINHEALTH (DEPI/DRFI/DMH/Cooperation Division/Inspector General of Health), 2 representatives from MINPAT (DPP/DCET) and MINEFI (DB/CAA), and one representative from the following agencies: the European Union, GTZ, the health services of the Protestant Church and the Coalition of NGOs operating in the health sector”.