Document of

The World Bank

FOR OFFICIAL USE ONLY

Report No. 6471-MAI

STAFF APPRAISAL REPORT

MALAWI

SECOND FAMILY HEALTH PROJECT

February 26, 1987

Population, Health and Nutrition Department

This document his a rewricled distribution and nmJ! he used b! recipienis onl in the performance oftheir official duties Its conltent mae not otherwiwe be di%clo%ed without World Bonk authoriiation.

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CURRENCY EQUIVALENTS

Currency Unit = Malavian Kwacha (K)US$1.00 = K2.00K1.00 = US$0.50

SDR1.00 = US$1.27

METRIC EQUIVALENTS

1 meter (m) = 3.28 feet1 square meter (sq.m.) = 10.76 square feet1 kilometer (km) = 0.62 miles1 square kilometer (sq.km) = 0.386 square miles

GOVERNMENT FISCAL YEAR

April 1 - March 31

This report is based on the findings of an appraisal mission that visitedMalawi in December 1985 and comprised Dr. V. Jagdish and Ms. F. Plunkett(IDA). and Messrs. S. Ayalew. B. Jacobson. P. C. Mohan, and M. Tayback(consultants), and on a donor coordination meeting that took place inSeptember 1986.

FOR OFFICIAL USK ONLY

MALAWI

SECOND FAMILY HZALTH PRDJBCT

CREDIT AND PROJECT SUMMARY

Borrower: Republic of Malawi

Beneficiaries: Ministry of Health. Department of Economic Planningand Development

Credit Amount: SDR 8.7 million (US$11.0 million equivalent)

Terms: Standard IDA Terms

Project The project objectives are to: (a) improve health status ofDescription: families. particularly of mothers and children through

expansion and strengthening of primary health care programs;(b) increase the availability and accessibility of chi.dspacing services within the maternal and child healthprogram; (c) further strengthen the Ministry of Health's(MOH) capacity to plan. manage and evaluate health servicesin the framework of a decentralized health system; and (d)design and implement a multi-sectoral family health programthrough other government agercies. The project is comprisedof two parts: The first part consists of activities to beundertaken by the MOH and includes (a) the building of healthcenters, replacement of a district hospital and the trainingof and provision of equipment and supplies to village healthcommittee members and health care workers to extend coverageof the primary health care system; (b) technical assistance.training, and provision of computer equipment to reorganizethe MOH and to strengthen drug production and supply. healthservice management and manpower development; and (c) theproduction of Information. Education and Communications (IEC)materials, health worker training, and the provision ofvehicles, drugs, and facilitied to strengthen maternal andchild health, child spacing and nutrition prograss. Thesecond part of the project consists of activities to becoordinated by the Department of Economic Planning andDevelopment (BP and D) and includes (a) training of women'swelfare workers and youth progra instructors and theproduction of educational materials on family health to beintroduced into functional literacy and youth programs; and(b) the production of IEC materials on family health andchild spacing concepts to be introduced into the mses media.

Benefits The project would directly benefit about 2 million peopleand Risks: throughout the country tbrough strengthening and expanding

primary health care and family health progrms and throughincreased accessibility of child spacing services. In themedium term, health status is expected to be improved by asignificant reduction in the incidence of infant and maternalmortality and morbidity. Population increase would be slowed

This document hu a restricted dtstribution and may be used by recipients only in the performanceof their official duties. Its contents may not otherwise be disclosed without World Bank authorization.

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through a significant increame in women using moderncontraceptives. The main project risk relates to weakimplementation capacity. The project minimises thi$ risk by(a) strengthening with additioal staffing and technicalassistance the units involved in carrying out the civil workscomponent; (b) coordination of *ulti-sectoral family healthactivities through the BP and D. which is being ctrengthenedwith technical assistance; (c) implemeotation of multi-sectoral family health activities through ministries withdemonstrated adequate implementation capacity; and (d)support for a comprehensive management review to support theMinistry' s reorganization.

Estiaated Cost: Local Foreign TotalCopq oneut - -(US$ Million)--

A. Primary Health Care 4.4 3.2 7.6D. Management. Manpower and Support Systems 1.8 1.5 3.3C. Family Health 3.0 2.8 5.8D. Project Management 0.2 1.3 1.5E. Health Through Other Ministries 2.7 1.6 4.3

Total Baseline Costs 12.1 10.4 22.5Physical Contingencies 0.7 0.8 1.5Price Contingencies 0.5 0.4 0.9TOTAL PROJECT COSTS a/ 13.3 11.6 24.9

Financing Plan:Local Foreign Total------- (US$ Million)-

IDA 4.7 6.3 11.0UIN!CU 1.2 1.4 2.6EDP 2.4 1.1 3.5KfW 2.2 1.9 4.1Government of the Netherlands .3 .6 .9UNYPA .9 - .9Government of Malawi (including taxes) 1.6 0.3 1.9TOTAL 13.3 11.6 24.9

Estimated Disbursement of IDA Credit:

IDA n 88 89 90 91 92 93------------US$ Millions------

Annual 0.6 2.4 3.0 2.7 1.7 0.6Cumulative 0.6 3.0 6.0 8.7 10.4 11.0

Rate of Return: N.A.

^ p IBRD 20099

a/ Includes US$0.4 million for taxes and duties.

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tALAWI

S8COND FAMILY IMALTH PAJ3CT

STAFF APPRAISAL RWORT

TABLE OF CONTETS

Credit an Project Summary Table of Contents

asic Data vDefinitions viAbbreviationo vii

I INTDUCTION I

II POPULATION AM HEALTH SECTOR STATUS AND ISSUS 2

A. Population 2B. Health 5C. Sectoral Issues 17D. Role of the Bank 19I. The First Phase of the National Health Plan 20

III THE PROJECT 22

A. Objectives and Design 22B. Smary Description 23C. Detailed Description 24

IV PRJCT COSTS N FINANCING 33

A. Costs 33B. Financing 36C. Procurement 39D. Disbursemnts 41K. Accounts and Audit 42

V PROJCT IMPLDIATION 43

A. Status of Project Preparation 43B. Organization and Management 43C. Monitoring. Reporting and Evaluation 44

VI PROJECT BENEFITS, JUSTIFICATION AM RISKS 47

A. Benefits and Justification 47B. Risks 49

VII ASSURANCES AND RECOMbM)ATIONS 51

TABLES:

1. Pr-ject Costs by kzpenditure Category 332. Project Costs by Functional Component 353. Project Costs by Financing Source 384. Procurement Table 40

ANNIOS:

1. Statistical Annez 532. Documents Available in Project File 683. Det&iled Cost Tables (Sumary Accounts) 69

CHARTS:

1. Current Organizational Structure of the Ministry of He,lth 772. Proposed Organizational Structure of the Ministry of Health 78

MAP

IBRD 20099 - Malawi. Primary Health Care Project

Mlv

MALAWUI

SECOND FAMILY HEALTH PROJECT

Basic Data

(All figures apply to 1985 unless otherwise indicated)

General:

Ares 118.500 sq. km.Area (land only) 94.300 sq.kaPopulation 7,154,000Population Density 74 per km2Rural population as a proportion of total population 91.5X (1977)Crude birth rate 54/1000 populationCrude death rate 23/1000 populationRate of population growth 3.2SInfant mortality rate 151/1000 live birthsGNP per capita (US$) 170

Health:

Population per physician 52,893Population per nurse 2,978Population per hospital bed 7,127Proportion of births attended by trained personnel 601 (1984)Proportion of woven receiving antenatal care by

trained personnel 701 (1984)Proportion of children between 1 and 2 years

of age fully immunized 55XGovernmsent ezpenditure on Ministry of Health

as proportion of total budget 4.81

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Definitions

Contraceptive Prevalence Rate: The percentage cf married women ofreproductive age who are using (or whomehusbands are using) any form ofcontraception.

Crude Birth Rate: The number of births per 1.000 populationin a given year.

Crude Death Rate: The number of deaths per 1.000 populationin a given year.

Dependency Ratio: The ratio of the economically dependentpart of the population to the productivepart, arbitrarily defined as the ratio ofthe young (those under 15 years of age)plus the elderly (those 65 years of ageand over) to the population in the"working ages" (those 15 to 64 years ofage).

Infant Mortality Rate: The number of deaths of infants under oneyear old in a given year per 1.000 livebirths in that year.

Life Upoctancy at Birth: The average number of years a newbornwould live if current age-specificmortality rate trends prevailing at thetime of birth were to continue.

Rate of Natural Increase: The rate at which a population isincreasing (or decreasing) in a givenyear due to surplus (or deficit) ofbirths over deaths expressed as apercentage of the base population.

Rate of Population Growth: The rate at vhich a population isincreasing (or decreasing) in a givenyear due to natural increase and netmigration, expressed as a percentage ofthe base population.

Total Fertility Rate: The average number of children that wouldbe born alive to a woman (or group ofwomen) during her lifetime if during herchild-bearing years she were to bearchildren at each age in accord withprevailing age-specific fertility rates.

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U BR8VIATIONS

ACMO Assistant Chief Medical OfficerCBR Crude Birth RateM3A Comunity Development AssistantM)R Crude Death RateCHSU Community Health Sciences UnitCHS Chief of Health ServicesCMS Central Medical StoresCO Clinical OfficerDMO District Medical OfficerIN Enrolled NurseSP and D Department of Economic Planning and

DevelopmentSPT Expanded Program of ImmunizationFFS Family Formation SurveyGDP Gross Dowestic ProductHA Health AssistantHI Health InspectorHSA Health Surveillance AssistontINC Information. Education and ComunicationIMR Infant Mortality RateIUD Intrauterine DeviceKfW Kreditanstalt fur WiederaufbauMA Medical AssistantMCH Maternal and Child HealthMDT Multiple Drug TherapyMOCS Ministry of Comunity ServicesMOH Ministry of HealthMowS Mit Axtry of Works and SuppliesMWRA Married Women of Reproductive AgeMYP Malawi Young PioneersNSO National Statistical OfficeOPC Office of the President and CabinetPHAM Private Hospitals' Association of MalawiPHC Primary Health CareRNI Rate of Natural IncreaseSCO Senior Clinical OfficerTBA Traditional Birth AttendantsTFR Total Fertility RateUNFPA United Nations Fund for Population ActivitiesUNICEF United Nations Children's FundUSAID United States Agency for International

DevelopmentVHC Village Health ComitteeWHO World Health Organization

MALAWI

SECOND FAMILY HEALTH PROJECT

I. INTRODUCTION

1.01 Malawi is a land-locked country located in east central Africa.It has a total land area of approximately 118.500 km2 of vhich Ekpproximately36.200 km2 is considered arable. Geographical:y, Malavi is bordered to thenorth by Tanzania; to the east, south and southwest by Mozambique; and tothe west by Zambia.

1.02 Malawi in divided into three administrative regions which varysignificantly in topography and climate. The Northern Region consistslargely of plateausi ranging from about 1,500 to. 2,500 meters high and withtemperature ranges between 15OC and 18oc. The Central Region has low lyingterrain along Lake Malawi rising to highland plateaus ranging from about1,000 to 1.200 meters and with a temperature range similar to the NorthernRegion. The Southern Region iS distinguished by widely varying climatic andtopological areas: the Shire Valley. in the extreme south, is very hot withan average annual temperature of 27oc; and the highest mountain, MountMulanje and the Shire highlands which have generally cool temperatures.

1.03 Between 1967 and 1979 Malawi's Gross Domestic Product (GDP) grewat an annual average rate of 6.8%. In 1979-1981 the economy of Malawi fellupon hard times. As a result of deteriorating terms of trade, drought anddisruptions on external transport routes the GDP fell by 2.7 percent;deficit on the current account and in the Government budget ballooned tounsustainable levels, and investment and savings rates fell sharply.

1.04 The Government launched a two-pronged effort to deal with theproblems of the economy: a stabilization program designed to reduce short-term fiscal and balance of payments disequilibria and a structuraladjustment progrua designed to improve efficiency of resource use and toensure that positive growth of per capita income could be re-established andmaintained over the medium and long-term, within the context of a manageablebalance of payments current account deficit. These programs have beensupported by three structural adjustment operations from the World Bank anda series of standbys and an Extended Financing Facility from theInternational Monetary Fund. As a result of the improved policyenvironment, more favorable climatic conditions and better export prices,the Malawian economy began to recover and in 1983-84 GDP grew at about 4.1percent with expainsion occurring in most sectors. The balance of paymentsdeficit on the current account was reduced and the budget deficit as apercentage of GDP was also reduced significantly. Despite continuedimplementation of these programs, Malawi's economic recovery has slowed in1985. It is estimated that GDP growth fell from 4.1 percent in 1984 to lessthan 2.5 percent in 1985. This was the result of exogenous factors. It isbelieved that the recent setbacks are temporary and that, with continuedimplementation of the Government's program, growth of per capita income canresume and financial equilibrium can be restored. Despite the progress madein the past twenty years, Malawi is still ote of the poorest countries inthe world.

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II. POPULATION AND HRALTH SECTOR STATUS AND ISSUES

A. Population

Demogri phic Situation

2.01 The popul4tion of Malawi was enumerated as 5.55 million inSeptemler 1977. It had increased by 37 percent since 1966. when theenumerited population was 4.04 million, thus implying an average annual rateof intor-censal growth of 2.9 percent. The population in 1985 was estimatedto be .15 million and the growth rate 3.2 pertent. Malawi is one of themost d4!nsely populated countries in Sub-Saharan Africa. equalled orsurpasoied only by Rwanda, Burundi, Nigeria and Uganda. The national densityaccord ng to the 1977 census was 59 inhabitants per ka2, and this may nowhave r sen to 74 per km2. There is considerable variation within thecountr, however, vith 1977 regional densities ranging from 24 in theNorthe:n Region. 60 in the Central Region, 87 in the Southern Region, anddistri :t densities varying from 11 to 230 persons per k2. The level ofurbani! ation in Malawi is low by any standard. If urban is defined aslocali:ies with a minimum of 2000 inhabitants. 8.5 percent of the populationin 197' lived in urban areas, and only 5 percent in 196t. The urban growthrate bhls been high, however, averaging 7.6 percent between 1966 and 1977.

2.02 Between 1966 and 1977 rural-to-urban moves made up about 35 to 45perceri: of all internal migration. Otber important migration streams wereinto a reas of commercial agricultural development or new agriculturalbettlElaents and out of areas with population pressure on limited landresouices (such as the Shire highlands) or areas lacking in general economicdevel(pment (such as most of the Northern Region). External migration.imporiant in past decades, has undoubtedly fallen and is expected tocontitue to diminish.

2.03 The level of mortality in Malawi from the 1950. to the mid 1970swas e ceptionally high by any standard, and declined only very slowly duringthis period. According to Bank estimates, life expectancy stood at only 37years in the late 1950s, then rose to 39 years by the mid-1960. and to 41years by the early 1970.. Theme low levels of life expectancy are dueprima.ily to extremely heavy mortality in childhood. Even in tne early1970s, the national infant mortality rate (IMR) was as high as 190 perthousind live births, with 36 percent of all children dying before reachingtheir fifth birthday. The IMR is estima^ed currently to be 151/1000 livebirtbh ranging from about 70/1000 in part,, of the Southern Region to aboutover ZOO/1000 in parts of the Central Region. A Family Formation Survey(FPS) undertaken in 1984 whose results are currently being analyzed, mayprovide some information into the causes of childhood mortality. Bycontiast, adult mortality appears to be unremarkable by Eastern Africanstandards. The level of fertility is high. In the mid 1970s, the totalfertility rate (TFR) was estimated at between 7.5 and 8.0 and is unlikely to

have changed since. Regionally the TFR is highest in the Central Region ataround 8.5 and lowest in the Southern Region between 7 and 7.5. The TPR inthe Northern Region is close to the national average.

Population Prolections

2.04 Rapid population growth in Malawi is all but inevitable over thenext two decades though a decline in fertility would reduce the rate ofpopulation growth. Thus, if fertility remains constant, the populationwould grow from 7.15 million in 1985 to 11.95 million in 2000 and 21.31million in 2015. If there is standard decline in fertility, the populationwould grow to 11.44 million in 2000 and 17.09 million in 2015. If there isaccelercted decline in fertility, the population would reach 10.63 millionin 2000 and 13.29 million in 2015.

MALAWI: POPULATION PROJECTIONS 1985-2015

Ratio of PopulationPopulation to Base 1985

(in millions) population in1985 2000 2015 2000 2015

A. Constant Fertility 7.15 11.95 21.31 167 298B. Standard Decline 7.15 11.44 17.09 160 239C. Accelerated Decline 7.15 10.63 13.29 149 186

Socio-economic Implications of Population Growth

2.05 Malawi faces the prospect of a 50 to 702 increase in populationsize over the coming 15 years. and a doubling or tripling witbin the next 30years. Such rapid population growth would have significant socio-economicconsequences. During the 1970s economic growth averaged 6.8S annually.while the population growth rate during the same period was 2.8 to 2.9S.This resulted in a continued increase in per capitn income. Between 1979and 1983 GDP growth fell to 2.82 per annum and has failed to matchpopulation growth, with a consequent slight decline in average income. Muchof the economic growth is due to estate and s'allholder agriculture.However, the growth of the agriculture sector is constrained by shortage ofland. The following table ehows the land required to support the populationat present nutritional levels and land productivity under three fertilityassumptions.

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TABLE

Land Needed to Support Percent of Total LandFertility Assumption Population (km2) Resources* Required

for Cultivat,on2000 2015 2000 2015

Constant Fertility 24,054 42,888 63 113(deficit)

Standard Decline 23,018 34.389 61 91Accelerated Decline 21.259 26,749 56 71

*not including land under estate cultivation in 1985.

Source: Malavi Population Sector Review: March 1986. Table 7.

2.06 If fertility remains constant, there are major implications forprimary education expenditures. To achieve current enrollment targets forprimary education, annual costs would have to rise from K24.4 million in1985 to K68.2 million in 2000 and to K159.3 million in 2015 (a 553S increasefroo 1985 to 2015). With accelerated fertility decline, annual costs wouldrise from K24.4 million in 1985 to K61.2 million in 2000 and to K66.1million in 2015 (a 1712 increase). Thus rapid fertility decline couldresult in annual savings of K93 million by 2015. Similarly, a decline infertility could cut annual secondary education expenditure within 30 yearsby 17X if fertility declines moderately, and by 43S if rapid fertilitydecline occurs. The need for expanded Maternal and Child Health (MCH)services will also increase substantially. If no fertility decline occurs,the number of children under 5 years of age would increase by 70S in 15years and would more than triple within 30 years to 4.5 million. In orderto maintain present levels of services, MCH expenditures would have to growby 3.8 percent annually. Since coverage is still very incomplete, muchlarger cost increases would be necessary to achieve an adequate standard ofMCH care. Reduction in fertility would not only reduce health costs, butenable the country to increase the quality and scope of the health services.

Population Policy

2.07 Although until recently population growth has not beenconsidtered a problem by the Governsent of Malavi, child spacing has come tobe recognized as a valuable component of MCH services on the grounds thatunregulated pregnancies endanger the health of both mothers and children.In 1982 the Govermnent decided to include child spacing services as part ofthe MCH program. The overall goal of the child spacing program is 'toreduce maternal morbidity and mortality by allowing the mother to restbetween pregnancies and to reduce infant and chiAd morbidity and mortality".The Government further stated that the introduction of child spacing

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services left intact the right of the family to have as many children asdesired, and that the child spacing program was not a tool of populationcontrol. These statements reflected deeply rooted attitudes in Malawiansociety favoring large numbers of children.

2.08 The last two years have seen significant changes in attitudes atall levels. There is increasing concern over the consequences of currentrates of population growth, and there is awareness that rapid growth may bea constraint to developsent. At the 1984 International PopulationConference in Mexico, the Government expressed its support for the conceptof educating the public about the benefits of small families. At therequest of the Government. IDA undertook a Population Sector Review innctober 1984. Two major recommendations emerged from the review. The firstwas that the Government should establish a formal capacity for populationpolicy formulation and planning. The second was that the MCH program andits child spacing component should be further developed and strengthened.For planning it was recommended that the Government establish a populationplanning capacity in the Economic Planning Division, Office of the Presidentand Cabinet, to develop a multi-sectoral population program. Populationrelated activities should be started in priority ministries, such asEducation, Community Services, Health, Agriculture, and the InformationDepartment of the Office of the President and Cabinet. For MCH and childspacing services it was recommended that the Child Spacing Program should berevised for incorporation into the five-year National Health Plan then underpreparation. A seminar vas held in June 1985 to discuss the report and themajor recommendations were accepted by the Government. The introduction ofthe child spacing program has generated interest among the public, despitethe limited availability of services. Though no systematic surveys have yetbeen undertaken, it is increasingly evident that demand is growing rapidly.Random record checks at child spacing clinics show that an increasingproportion of clients come from outside the catchment areas. People arewilling to travel long distances to obtain contraceptives. This phenomenonhas been observed in hospitals, in urban and rural areas alike. Demand forservices has led the MOH to develop plans for a nationwide child spacingprogram. The results of the 1984 Family Formation Survey financed under thefirst IDA-supported health project are expected shortly and will contributeto a better understanding of the determinants of fertility in Malawi.

B. Health

Health and Nutrition Status

2.09 Mortality is high, particularly amongst infants and children.The Crude Death Rate (CDR) is estimated to be 23 and the Infant MortalityRate (IMR) 151. While mortality has declined from its high levels in the1950s and 1960s (CDR 30, IKR 200), compared to neighboring countries.Malavi's infant and child mortality are very high. Infant mortality inrural areas is reported to be twice that in urban areas. The leading causes

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of death (inpatient data) in children 0-4 years are: measles (16.21).pneumonia (13.02). nutritional deficiency (11.2Z). malaria (10.1). nemia(9.1) and diarrheal diseases (8.41) (Annez 1. Table 1). These data showthat 57 percent of all deaths in Malawi occur in children under five yearsof age. and that malnutrition directly or indirectly accounts for at leastone-third of all deaths in the country.

2.10 Data on morbidity is obtained from outpatient facilities only.The leading causes of morbidity are: malaria, respiratory infections,diarrheal diseases, skin diseases, inflamatory eye diseases, traumasvenereal diseases, and hookworm and other helminthic infestations. Amongchildren 0-4 yeare. malaria (35.6%). respiratory infections (19.81).diarrheal diseases (8M7), inflanmatory eye diseases (7.91) and skindiseases (5.6S) (Annez 1 Table 2) are the five leading causes of outpatientmorbidity. These account for 77.6Z of morbidity of children and vould berelatively easily preventable.

2.11 Nutritional information is sparse and generally outdated. The1981 National Sample Survey of Agriculture revealed that Malawian infantshave a very high level of stunting. A distinct growth fUltering begins at 6months of age, possibly due to insufficient food intake and the onset ofinfectious diseases. The prevalence of underweight and wasting was found tobe higher between 6-24 months, coinciding with the nutritionally criticalperiod of weaning. Prevalence of stunting increases r"ith age through thefirst three years when it reaches a peak of 652 and levels off at 601 forthe remaining two years. This shows that most children get stunted duringthe weaning period, a time of aximal growth. The survey found over 502 ofpreschool children to be chronically malnourished (below 2 standarddeviations weight for age - ranging from 472 to 651) in different parts ofthe country. This compares with 371 in Kenya and 282 in Zimbabwe. This isthe highest in Eastern and Southern Africa (except for Ethiopia). A morerecent survey (in one district only) has highlighted the problem of foodavailability. Sixty-nine percent of women interviewed said they hadinsufficient food for their families. Taking April as the first month ofthe harvest, 301 of women reported they had exhausted food supplies bySeptember and 602 by December. The EP and D has recently begun work onformulating a food and nutrition policy. This is being supported through anMDA-financed agricultural project. Since the nutrition problem in Halawi isprimarily one of shortage of food, changes in agricultural policy are likelyto have a greater impact on nutrition than specific nutrition programinterventions. Nevertheless, other necessary nutrition activities areincluded in the proposed project.

Health Plans

2.12 Shortly after independence, the Government launched its firstfive-year plan (1965-69). Resources were devoted prinmrily to curativeservices and development of nursing manpower. Evaluations of planisplementation showed that these interventions, though important, wereunlikely by themselves to improve health status. With assistance from the

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World Health Organization (WHO). the Government produced a 15-year healthplan (1973-1988) whose priorities yere: development of basic healthservices; control of comunicable diseases; manpower development;construction of new hospitals and improvement of mzisting ones; andreorganization of the MOH. In 1975 emphsis was placed on the expansion ofmaternal and child health services and in 1978 the MOH introduced a primaryhealth care (PHC) program on a pilot basis. Implementation of the 15-yearhealth plan was hampered by: lack of adequate financial resources, scarcityof trained manpower and inexperienced health administrators. Recognizingthat the 15-year plan covered too long a tise period and was outdated, theMOH began preparation of a 10-year National Health Plan in 1983 through thefirst L1A-supported health project.

2.13 National Health Plan (1986-1995) and Health Policy. The NationalHealth Plan has met the following medium-term goals: ...to achieve a dropin early childhood mortality of 33.32 over a fiveyear period; to achieve animprovesent in maternal health; and to impact on the extent and severity ofillness due to major causes of morbidity 5 years of age and over through thePrimary Health Care approach and/or core health service*s. To accomplishthese goals, six specific objectives have been formulated: (1) improv'access to a rational network of available and acceptable facilities byextending the peripheral services. especially comunity based services andby modestly strengthening hospital facilities and staffing; (2) establisheffective mechanisms for the MOH manpower development and the monitoring ofdeployment; (3) improve the management support of the enhanced healthdelivery system; (4) improve child survival of the under five age group;(5) improve health status generally by strengthening relevant programs; and(6) improve the nutritional status of mothers and children.

2.14 For the first five years (1986-1990) the plan assumes that therewill be no real growth in the MOH s recurrent budget. Recognizing thebudgetary constraints, emphasis is placed on improved cost recovery and costeffectiveness. At the same time emphasis is placed on consolidation ofexisting services and expansion of prioritv health programs which have loi.recurrent cost or manpower isplications. Recognizing the seriousness of thenutrition problem. the Plan has highlighted nutrition activities. Given theresource constraints the MOH faces on the one hand, and the need forpriority health programs on the other. the plati is sodest in its resourcerequirements and in its expectations.

Organization of Health Services

2.15 MOH has primary responsibility for the development of policies.strategies and programs for health care in Halawi. Public health servicesare provided mainly by the MOH. The Private Hospitals Association of Malawi(PHAM) made up of church-related and other private voluntary agencyfacilities is the largest non-governsent provider of health services.

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2.16 MOH services are provided at five levels: comunity, healthcenters and rural hospitals, district hospitals. e ntral hospitals andspecial hospitals. Services at the comunity level consist of an eztensivenetwork of outreach activities through mobile clinics and the PHC program.(paras. 2.33-34). Comunity level services strese activities andinterventions associated with under fives care (health education.environmental sanitation. diarrheal disease control, immunizations, pre- andpost-natal care, and growth monitoring). The MOH runs 162 bealth centersand 19 rural hospitals which offer similar services: curative care, pre-natal, natal ard post-natal care, infant and child care, and comaunityservices. Many health centers also run nutrition clinics (nutritioneducation, food preparation demonstrations and free food supplements).There are 21 district hospitals run by the MOH which serve as referralfacilities for health centers. In addition, they offer all preventiveservices available at the health center. The two central hospitals functionas referral hospitals for their respective regions. They are also used astraining facilities for various training institutions. There is one generalbospital. Special hospitals offer specialized services, including mentalhealth services and inpatient care for leprosy and tuberculosis cases.There are considerable regional variations with regard to the distributionand coverage of facilities. Twenty percent of all health facilities aresituated in the northern region. 332 in the central region and 471 in thesouthern region for populations of 860,000. 2.785.000. and 3.432.000respectively. The percentage of population within 8ka of a health facilityis 57, 70, and 100 for the northern, central, and southern regionsrespectively. There are a total of 17.664 beds in the country of which6.017 are in MOH facilities. Utilization of hospital services (bothinpatient and outpatient) is very high (Annex 1. Table 3). The same is thecase with services provided at health centers and sub-centers, where dailypatient loads range between 100 and 150.

2.17 PHAM operates 20 district hospitals. 19 rural hospitals, and 97health centers in the country. PHAM hospitals account for just over one-third of all adcissions. PHAM facilities see about 142 of total outpatientfirst attendances. Services offered by PHAM are similar to those of theMOH. At PRAM facilities fees are charged for curative services though mostpreventive services are available free of charge. Despite efforts by theMOH and the PHAM secretariat the quality of services provided at individualPHAM facilities varies enormously.

2.18 PHAM provides about 451 of the country's health services and itstraining institutions produce nearly 701 of Malawi's enrolled nurses. Dueto severe financial constraints however, a number of PHAM units have beenasking the MOH to take over operations of these units. The MOH, whichprovides an annual subsidy to PHAM, is not considering any take-over.Instead plans have been formulated to ensure close cooperation andcoordination between PHAM and MOH. These plans would enable the MOH to:establisb peripheral health staff positions in PHAM facilities; utilize thetraining capacity of PHAM for its training needs; integrate district levelsupervision and in-service training for PHAM and MOH programs; adopt

standardized preventive and curative interventions at PHAJ and MOH healthfacilities; and standardize job descriptions and training for health staff.

2.19 Local government authorities and other agencies such as the army.police, estates and industries provide curative and preventive services fortheir employees. Private medical practice is limited to about 35 physiciansin urban areas. There are about 5,000 traditional healers and 5.000traditional birth attendants (TBAs) scattered throughout the country. ByJuly 1985 about 800 TBAs had been trained by the MOH. Formal links betweenthe MOH and traditional practitioners do not exist.

Management and Administration

2.20 The Principal Secretary is the senior manager in the MOH vho isresponsible for both its technical and administrative branch (Chart I). TheChief of Health Services (CHS) has overall responsibility for all technicalservices. He is assisted by senior technical staff. On the administrativeside. the Deputy Secretary is responsible for the Planning Unit and for theadministrative units such as finance. personnel, administration and internalaudit. Below the MOH. the health care delivery system has three levels.viz, regional, district and peripheral. Each of the country's three regionshas a Regional Health Team comprising of a Regional Public Health Inspectorand a Regional MCH Coordinator who report directly to their respective unitsat the MOH. The District Medical Officer (DMO) is responsible for allhealth services in the district and reports directly to the CHS. Peripheralhealth services are managed by the medical assistant in charge of the healthcenter. Together with the health assistant he is responsible for supportingprimary health care activities at the village level.

2.21 With increasing emphasis on preventive and rural h..slth services,ad hoc organizational and management changes have been made periodically inthe structure of the MOH. However, the organization structure iscumbersome. Recognizing these problems, the Malawi Civil Service ReviewComission undertook a comprehensive study of the MOH in 1984. The studyhighlighted the MOH's major management problems. First, the objectives ofthe MCH and the individual departments were no longer appropriate to thechanging health needs of Malawi. Second. lines of authority were oftenunclear. Accountability followed professional rather than functional lines.Third. individual roles vere inadequately defined and often there were nojob descriptions. This led to ad hoc allocation of responsibilities andoften resulted in reduced efficiency. Fourth, there were too many levels ofauthority in the administrative branch of the MOH. At the same time, thereverse occurred at the district level where a sanager was expected tosanage too large working groups. Fifth, the decision making process wasover-centralized. Routine operational issues were referred to the CHS whichshould have been dealt with lover down the hierarchy. Sixth, managementsupport systems were inadequate. There was no firm control or monitoring ofexpenditures particularly with regard to vehicles and supplies. This mayhave been due to the fact that a number of positions in the establishment

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list could not be filled because of budgetary constraints. Seventh, theRegional Health Teams and District Health Teams typically lacked experiencein planning and evaluation. Finally, there was inadequate supervision ofperipheral health workers due largely to poorly developed supervisorysystems, lack of training in supervision, lack of delegation of authorityand transport shortages.

2.22 The recommendations of the Civil Service Review Commission havebeen studied by the MOH and a new organizational structure has been proposed(Chart II). The recommendations of the Commission together with the MOH'sproposals have been reviewed by an inter-ministerial committee chaired bythe Secretary to the Office of the President and Cabinet. Additionalstudies are being carried out through the IDA health project. Duringnegotiations assurances were obtained that the Government will submit to IDAfor its review and coments, a revised organization chart for MOH bySeptember 1, 1987, and formally adopt such revised organization chart byOctober 1, 1987 (para. 7.Ola).

Pharmaceutical Procurement and Distribution

2.23 Pharmaceuticals for the health sector are supplied by the CentralMedical Stores (CMS), a self-financing and self-accounting body since April1984. In 1983-84 its annual turnover was around K4 million. Pricing ofdrugs is currently fixed at CIF value plus 12.5X to cover all operatingcosts (up from 31 before April 1984). The CMS is responsible forprocurement, inventory control and store keeping, drug assembly, repackagingand distribution, and manufacture of simple products. Since 1983, a programof continued upgrading of its operating procedures has beer underway.Facilities for formulation and manufacture of simple drugs have beenestablished in Blantyre. Regional stores are being con*tructed in Lilongweand Mzuzu. Implementation of plans to improve drug procurement andmonitoring has begun. These activities when fully operational are expectedto result in cost savings of K900,000 annually. Most of the key elements inan essential drugs policy are either already implemented or are underdiscussion. Thus, an Essential Drugs List was drawn up in 1985 and is beingrevised; procurement for the public sector is under generic names throughICB, and legislation on pharmaceutical matters has been drafted. Thedevelopment of a district level network, equipping of a quality controllaboratory, and further training of staff constitute the next phase ofdevelopment of the pharmaceutical system.

Manpower and Training

2.24 T ere were 4,962 established positions in the MOH in June 1984.Nearly 151 of these positions were vacant (Annex 1, Table 4). Aconsiderable amount of manpower development activities have been undertakenduring the past 5 years. Annex 1, Table 5 presents the growth of healthstaff between 1978 and 1983 by category. From this table it is clear thatsome categories of staff are particularly affected--the number of medicalofficers and dentists declined during this period whereas the number of

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clinical officers. enrolled nurses. laboratory technicians and healtheducator. (manpower pril_rily staffing rural health facilities) rosesubstantially. The NO has concentrated upon the develoyeant of healthauziliaries ed has been able to post soot staff to rural hcalth facilities.Staffing patterns are being reviewed and the MOH plans to add one healthssistant and comnalty health nurse at each health center. With low

attrition rates (about 5S per annua) it Lo likely that the MOH will be ableto produce adequate numbers of health auxiliaries to staff its facilitiesduring the plan period (Annex 1. Table 6). Furthermore, PHANtraining facilties produce more enrolled nurses than they can absorb butthe MMB can utilise the surplus. The proposed project does not requiresignificant additional manpower. The NOR's training facilities are expectedto be able to supply all required health auxiliaries. Tho project itselfwould * phasise continuing education at this stage.

2.25 The question of shortage of doctors is. however, another matter.Malwi does not have a mdical school. In the past, the country hba sentcandidates abroad to pursue medical studies. However, difficulties insecuring admissions to overseas universities and problems in persuadingdoctors to return has led to a chronic and serious shortage. The MOB istborefore considering establishing a medical school in the country.Feasibility studies have been carried out. These studios have highlightedthe bigh cost of establishing a separate medical school and a teachinghospital. A review of optiono to establish a medical school has recentlybeen completed by the NOR with support from the Overseas DevelopmentAdainistration and the Federal Republic of Germany. The emphasis on'comnity bealth in the proposed curriculum is particularly attractive andcould be tbh basis for the developaent of appropriate medical education inMalawi. The use of mxisting hospitals for the proposed medical school wouldsignificantly reduce the coot of such a project. Preparatory work on aproject proposal has begun. A medical school proposal has been included inthe Public Sector lnvestment Programs it is possible in our view for Malawito consider establishing such a medical school.

2.26 Ifforts to establish continuing education programs for healthworikers began in 1964. However, few facilities eoist and continuingeducation prograas are hold at hotels at high costs and at infrequentintervals. The other major problo with continuing education programs is thelack of coordination aaong major service prograns resulting in duplicationand wastage of scarce resources. These problems underline the inability ofthe NMM to plan and imploemnt continuing education progrms.

Maternal and Child Health (MCI)

2.27 Tbh objectives of the MCH program are to: strengthen and expandMCM services throughout the countrys strengthen the training of healthwoikercs increase immunisation coverage of all children to 802 by 1990;improve nutritional status of children and decrease the incidence ofundermeLght children through growth monitoring with nutrition education and

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food supplementation where neeeseary; use Traditional Birth Attendants(TBAs) to deliver MCH services; and, promote child spacing. The MCH programwao initiated in 1973 under the Assistant Chief Medical Officer (ACMD), MCH.At the regional level, an MCH supervisor oversee MCH activities in each ofthe three regions. At the district level, a member of the ezisting districthealth staff, usually a nurse. is appointed as MCH coordinator.

2.28 Child care services are provided through 1,075 static and outreachunder-five clinics throughout the country. There were about 600,000 firstattendances of children under one year of age in 1983. Immunizations areprovided as part of the MCR program. Despite an impressive beginning.shortage of equipment and suppliex, weak cold chain and poorly trained staffhave resulted in the proportion of fully immunized c1ildren to decrease byabout 202 since 1982. Present coverage levels are about 352. Nutritionalsurveillance and education activities are undertaken at health clinics. Thequality and impact of these activities have not been evaluated.

2.29 In 1984. an evaluation of MCH activities was undertaken. Theevaluation confirmed earlier field observations that the quality of servicesis consistently high and the people attending appeared to have confidence inthe staff providing the services. However, coverage appears to be far fromadequate; about 60Z of women have at least one antenatal visit, some 402 ofall pregnant women deliver at home, and over 502 of children aged four yearsand under are not being reached by MCH services. Services are constrainedby lack of transport, drugs and IEC materials. Mothers with young babiesunder two years do not seem to use the services as much as mothers witholder children. Also, use of facilities for post-partum services isvirtually non-existent. This. together with low immunization coverage andpoor nutrition, may be significant reasons for Malavi's high IMR.Unregulated fertility, often resulting in short birth intervals and earlyweaning, is another factor associated with continued high infant and childmortality rates.

Child Spacing

2.30 In light of the continuing problems of infant and child mortality,the MOH organized a workshop on Health and the Family .n 1981 whichrecommended the introduction of child spacing services. In 1983 an initialtwo-year plan to initiate child spacing was prepared. The main objectivesof the plan were to: orient health staff on child spacing; providetechnical training to providers of child spacing services; develop thecapability of the MOH to implement the child spacing program; organizeseminars to acquaint community leaders and the public about child spacing;provide child spacing services as an integral part of MCH services atvarious levels of the health care delivery syotem; and develop a simplesystem for monitoring and evaluation of child spacing activities.

2.31 In 1983, child spacing services were introduced in the two centralhospitals at Blantyre end Lilongwe and the Zomba General Hospital.Initially, theme services were provided by doctors alone. Shortly after the

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program was initiated, nurse-midwives were trained in child spacing, andcurrently they too provide service. The participation of midwives hasresulted in a steady rise in the number of acceptors. As a result, childxpacing clinics are now held every working day rather than once a week. In1984 the total number of attendances at the Queen Elizabeth Hospital's childspacing clinic were 8,281, of which 2.138 were new client. Demand forservices at the hospitals in Lilongwe and Zomba has also been growingsteadily. Child spacing services are now available at all districthospitals and preliminary indications are very encouraging. No estimates ofcontraceptive prevalence rates are currently available. Training oftrainers and service providers has exceeded the targets. The MOH has begunto use mass media to provide general information on family health.Comunity seminars have not yet been organized but are planned during thisyear. Contraceptives are available through public and private healthfacilities. While no social marketing programs have yet been developed.contraceptives are increasingly becoming available through pharmacies and arange of other commercial channels.

2.32 Despite a promising start, the program is experiencing problemswhich have important implications for future child spacing plans. Theyrelate to inadequacy of facilities, supplies and logistics constraints andlack of a good reporting system. Lilongwe lacks facilitiea to provide childspacing services; services Are provided at a run down clinic that is heavilyovercrowded. The rapid and unforeseen growth in demand has resulted in asevere shortage of contraceptive supplies. There is still limitedknowledge of potential demand and a lack of coordination between MOHheadquarters in Lilongwe. which orders commodities, and the CMS (CMS), whichhandles customs clearance, storage, and distribution of contraceptives.Demand has been difficult to estimate since child spacing services have onlyrecently become available and the MOH has no survey mechanism or other meansof obtaining necessary information. Forms for information on child spacingusers are now being designed. The program urgently needs a simple datacollection and record system supplemented by periodic sample surveys thatcan be used by both Government and PHAM hospitals.

Primary Health Care (PHC)

2.33 Following naLional seminars in 1978 the MOH began implementationof PHC on a pilot basis in three districts. The PHC approach adopted byMalawi consists of training district area and health center staff inconcepts, community sensitization, and the establishment of village healthcomittees (VHC). VHCs art responsible for initiating PHC activities at thecommunity level, PHC activities were introduced through the IDA-supportedfirst health project. Details of the program are available in the projectfile. An evaluation of these activities undertaken in 1982 revealed anumber of weaknesses in the approach. In 1983 the program was revisedsignificantly and PHC activities were begun in a phased manner through thefirst project. PHC activities were started in the three districts, Mzimba,Dowa and Mwanze; at the same time the health infrastructure in these

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districts was strengthened by upgrading six facilities to primary healthcenters. In mid-1985, PHC activities were extended to iz more districts(namely: Mulange. Dodma, Ntcheu, Karongea Nsaage ad Chikvwa), wheresupporting health infrastructure was adequate.

2.34 Soon thereafter, in October 1985. the MOB undertock a programevaluation in the three districts in which PRC was first starteds itconcluded that PRC approach in Malawi is appropriately cautious Maeducation intensive. PRC activities are introduced into an area only afterVICa have been formed and trained. The evaluation found that VICsinteracted well with health vorkers in their respective areas. Healthworkers visited VHCs on a sonthly basis and the quality of the supervisionwas good; the provision of bicycles at the health center level considerablyfacilitated supervisory activities. The NOR has concluded that one healthworker can effectively supervise 3 VTCs. Participation of communities wasgood and an understanding and acceptance of the concept of self reliane wasdeveloping. The evaluation concluded that the education intensive approachadopted by Malawi is providing a solid base for nationwide expansions itcould not. however, assess the impact on health status because of the ahortimplementation period. Though the PHC program is making gains theevaluation identified three major probles areas: scarce transport; pressureof work; and the need for continuing education. Area team and VRCs feltthat there was poor supervision from the district level because districtteams lacked transport. In adlition to strengthening the nobility ofdistrict team, the evaluatiot recommended continued use of bicycles andmotorcycles at the area and village levels to facilitate further theimplemnntation of field activities. Area teams were expected to cover largearea and hence the pressure of work was significant. Steps needtd to betaken to reduce the work load of area teams through perhaps introduction ofextension assistants or part time workers at the village level. Theevaluation recomended strengthening continuing education program fordistrict PHC teams, area teams, health workers and village healthcomittees.

Community Health Sciences Unit (CRSU): Disease Control and Prevention

2.35 Health planning and evaluation is made difficult by the scarcityof valid epidemiological data. The capacity of the MOR to collect andsnalyse health status information is very limited. Various diseao controlprogras (bilharzia, tuberculosis. sexually transmitted diseases.onchocerciasis, malaria, and leprosy control programs) historically havebeen developed with little coordination between each other and with thehealth system as a whole. There are no laboratory facilities to providethe support for field surveys and analyses. Diaposis and treat met cfcses at health centers is unsatisfactory prim-rily due to inadequatetraining of health staff and lack of equipment and supplies for fieldsurveys and analyses. Under the ongoing IDA-assisted health project, theCHSU with the necessary laboratory services is being established. The cHsUwill also be used to provide services normally required of a national publichealth laboratory which Malawi currently lacks.

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2.36 The CESU is being established as part of the ten-year health plan.The main goal is to improve managemnt and routine health informationsystem. coordinate and aonitor all disease control program activities andpromote applied research and the use of epidemiological skills and reviveeuvirozmental health activities Some of theme activities have alreadystarted. e.g.. coordination and monitoring disease control program. Theconstruction of the CHSU is now under way and will be completed by ndApril. 1987. Equipment and vehicles used by existing programs will beabsorbed by the unit and is being supplemented under the first healthproject.

2.37 The controller (Community Health Services) will head CGSU whichwould have two sections. A field activities section, headed by anepidemiologist, would be responsible for malaria, diarrhoea,achistosomiasis, iodine deficiency. onchocerciasis, Vitamin A deficiency.sezually tranmitted diseases, leprosy, tuberculosis, envirommental healthprogram and epidemiology. This section will also be responsible for thecollection and evaluation of health statistics, providing the evaluatedoutput to the MOH Planning Unit. The pattologist of the Kasuzu CentralHospital in Lilongwe would head the laboratory services section coveringmicrobiology, biochemistry and parasitology.

2.38 Although the staff of existing programs vill form part of the newunit. training will be required for staff with skills not now available.The unit head hs been identified, and a pathologist and a parasitologistare available. An epidemiologist, sociologist, and biochemist are intraining and two laboratory technologists will need external training. Thesix persons required to staff the field activities unit will be drawn fromthe health inspectors, registered community health nurses, and clinicalofficers, some of whom are now employed under ezisting disease controlprogram which will be subsumed under the CH8U. They will receive trainingin Malawi in survey methodology from the epidemiologist recruited to assistin PEC activities. Two years will be needed to establish the facilities andtrain staff. from January. 1988, four consultants pravided by VHO with UNDPfunding, an epidemiologist, microbiologist. biochemist and laboratorytechnologist, will be made available for two years to assist in establishingthe unit's work program and the smooth functioning of laboratory services.Trom that date, the unit will be able to: (a) undertake epidemiologicalstudies and surveyas (b) coordinate, monitor and periodically evaluate alldisease control programs; and (c) coordinate ongoing research prograns in,for example, malaria, diarrhoea, schistomomiasis, trypanosomiasis andleprosy.

Health Expenditures and External Assistance

2.39 Government resources finance a large proportion of the MOH'srecurrent budget. The MOH's recurrent budget rose from K18.7 million in1981/82 to n estimated K36.7 million in 1985/86 (Annex 1, Table 7). Itaccounts for about 6.72 of the overall Government recurrent budget. About

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1,82 or K19.3 million cam from the Treaury. The remaining 252 is expectedIao come from fees and eaternal sources. Betveen 1981/82 and 1985/86 non-t reasury support for the recurrent budget has ranged between 192 and 32S.1lupport for drugs and medical personnel cover a large proportion of externaltupport. Annez 1. Table 8 shows that revenue from fees have not kept pacewith the growth of health expenditure. Between 1975/76 and 1984/85 revenuefrom fees as a percent of gross MOH expenditure declined from 4.32 to 3.62.Fee schedules have been revised, and it is expected thiat revenue from feeswould rise to 4.32 of gross MOR expenditure in 1985/86. Approximately 262of the recurrent budget is spent on salaries and wages.

2,40 Health expenditures cannot be broken down easily by programs.Arnex 1, Table 9 shows actual MOH expenditure by activity category in1985/86. Eighty-one percent of the budget is expected to be spent onhospitals and only 62 on preventive activitiez. Since hospitals do supportsome preventive activities, it is probable that the percentage spent onpreventive activities is somewhat higher. Between 1976/77 and 1985/86 totalHOA expenditure has increased about four-fold with an average growth of16 82 (Annex 1, Table 10). When expenditures are adjusted for inflation.the MOR's budget has still increased by about two-fold with an averageanuiual growth of 6.42. The MOH's share of the overall governaent recurrentbudget has ranged between 7.62 in 1975/76 and 6.72 in 1984/85. Despite thisgrowth, the NOH's recurrent budget position is difficult and expenditureshave consistently exceeded approved budgets by about 352. This has beendue, in part, to inadequate budgeting for pipeline projects and to lack of 8coq)rehensive health plan and budgetary controls. On a per capita basis,hea;.th expenditures grew from K1.2 in 1975/76 to K4.3 in 1985/86 in currentprices and from K1.6 to K2.2 in constant prices.

2.41 The preparation of the national health plan (parss 2.13-2.14) hasresulted in a more realistic projection of incremental recurrent costs. Forthe first five years of the plan costs are expected to be K4.0 million atconst:ant prices. Activities begiining in the first three years of the five-year program would have incremntal recurrent costs of K2.5 million atconst ant prices. The MOR would need an additional K2.03 maillion in therecurrent budget in order to adequately fund all ongoing and proposedactivities during this period. A significant increase in Treasuryallocations is unlikely during the plan's first five years. In view of thediffie,ult financial situation, the MOH has explored carefully for sources offinan,ing of bealth services. Fees charged for private patients and severalfee schedules for general patients were revised in 1984. As a result feecollec:tion is expected to rise from K570,000 in 1982/83 (3.32 of gross NORezpenciture) to K1.6 million in 1985/86. or 4.32 of gross MOH expenditure.It is projected that in 1990 income from fees will, rise to K5.3 million(6.82 of MOH expenditure). Although important from the point of view ofincrerised service use rationalization, this source will continue to belimited. The other major area being pursued is improvement of theoperational efficiency of the MOh. With restructuring of the CMS and thestrengthening of the pharmaceutical sector, annual savings of K910,000 areexpected. Other cost saving measures, particularly with regard to houpital

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management, *re being introduced. The MOB expects to save [1.2 million in1986 rising to K4.3 million by 1990 through improved efficieucy of itsoperations.

2.42 The approved capital budget of the MNO, as a percent of totalGovernment budget, increaced from about 1.22 in 1977/78 to 4.82 in 1985/86.Actual expendituren in constcat price. per capita increased from [0.19 in1977/78 to KO.56 in 1983/84. The capital budget of the MOH for 1985/86is estimated to be [7.5 million. Of thic, K6.3 million is ezternallyfinanced (Annex 1. Table 11). Only 5l of the capital budget in financedfrom Government resources. Alth4ugh under-utilization had been a prominentfeature of the capital budget in the post, the situation has improved inrecent years. From 1976/77 to 1983/84 under-implementation averaged 282ranging from 42S in 1981/82 to 62 in 1983/84. Limitations of the recurrentbudget and delays in construction were the main constraints.

2.43 Income to PHAM is derived from Governmsent allocations. ftee andoverseas donotions. MOE contributions account for about 35S, fees 34S andoverseas donations for about 302 of its income. The total Governmentassistance to PRAM in 1984/85 was abwat 11 of MOR expenditure. In 1985/86[2.5 million (or 112) of the MOR budget has been allocated. The MOR grantsupports: (a) cost of Malawian staff employed by PRAM, and (b) cost of drugsfor TB, leprocy, sexually transmitted diseases and bilharzia. In addition.vaccines for immunization of the under-five population are provided free.On the development side. PRAM units have been built with funds fromagricultural development projects and external financing.

C. Sectoral Issues

2.44 The implications of rapid population growth have been discussedearlier (paras 2.05-2.06). The rate of growth would slow in primarily twoways: (a) by mass emigration; or, (b) by a significant fall in fertility.Large-scale emigration to neighboring countries, all of which areexperiencing high rates of population growth and economic problemsthemselves, is no longer an option. Though reducing fertility is the onlypractical and important solution, analysis of population problems extetdsbeyond fertility or migration. Population programs must address issues suchas women's development and literacy, health and education.

2.45 Fertility reduction on the scale required to alleviate theproblems of population growth can only be achieved through undervtanding ofthese problems by both the Government and the public, followed by thedevelopment of appropriate population policies by the Government and theirimplementaition through a multi-sectoral family health program. TheGovernumvt does not support any direct reference to limiting family mire.and informs fasilies to preserve the right to have as many children as theydesire. The present policy consists of providing child specing services tothose who want it, and establishing soxcial and educational programs wbich

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will develop awareness of the problem of rapid population growth.

2.46 The Governmet has mae signif icant offorts to reduce the infantand child mortality rates through increaed access to and improved qualityof health services. These efforts have been successful in parts of theSouthern Region where the DM has dropped to aroun 75. In other parts ofthe country, however, the 0Govrnmet's efforts have hd limited impact. Tobring down infant and child mortality, selective targeting of interventionswould have a significant impact. However, this approach has not beenfollowed and hs resulted in a lack of focus on priority activities. Manyfamily health and dis*ase control programs are still new and have not yetcovered the whole country. Health services are still not readily accessiblein many rural areas of the country. Shortages of drug supplies in remotehealth facilities are ecomon. As mew health programs have been implementedover the years. the saagmnot of the MOE has not evolved to respond to thechanging environments decision-making is still over-centralized. There islittle coordination among health progrm units at the central level, andconsequently the effeetiveness of service delivery suffers at operationallevels. The roles of the regional and district levels need to be moreclearly efied. linally, are such as financial plannig, budgeting andmanpower ca.ag"eat are poorly staffed and managed. Rospital anagment isweak.. The absenc of trained bospital administrators and the sevreovercrowding make hospitals inefficient institutions often providing bsicservices at higher unit costs.

2.47 Concerted attepts 'o addreuu ItiAwil? minutririon problem nvenot yet been made althogh nutrition activities are undertaken an part ofthe MCI progrm. In July 1986 the Gvenment held a seminar on thenutrition problem for Pricipal Secretaries. A decision to establish a Foodand Nutrition Unit in the *P and D has been token. The unit is expocted tocoordinate end maintain an overview of activities related to food securityand nutritiou in Maiawi, estimte the nutrition effects of selected policiesato programs, help develop early warning and nutritional surveillaneesystem and determine cost-effective ways to reach nutrition goals.

2.48 Three major needs merge fron the proceeding sectoral analysis:(a) development oad strengthening of a decentralized health systems (b)institution buildinj fox health and populations and (c) expansion ofpopulation activities. The development and strengthening of a decentralizedhealth systm (with a strong focus on pri$ary bealth care) would make basickealth care accessible in the more re ote rural areas. This emphasis oevillage and comraity health given Malawi's stage of development would beappropriate. It would also belp focus diseas prevention, nutrition andfamily health activities. In the MM and the largse hospicals there is aneed for strngtbening organizational manageent, financial managemet andcontrols (including efficiency improvements, cost saving aesures and costrecovery), planning and budgeting and manpower developomnt. ectoralplaning through strongthening of the 3P and D is part of the institutiondevelopment objective. Information on child spacing would be disseminatedto a larger audience and would belp stimulate demoad for services.

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D. Role of the ank

2.49 IDA ha been involved in the bealth sector in Malawi since 1971whe the first Karongs Rral Developmt Project included a healthcomponent. In all, ten agricultural projects have included healthcomponents with e total investment of about US$4.5 million. Inputs haveranged from enlarging and modernizing the Karonga Hospitals to the bilhar.iacontrol programs. and the development of sub-centers and health posts. In1980 IDA undertook a health sector review. In late 1982 the GOvernmeatdecided that, for purposes of facilitating child spacing on health grounds.child spacing services would be available as an integral part of the MMprogram. A child spacing component was therefore included in the flrsthealth project. Since this very cautious beginning, child spacing serviceshave expanded steadily. and dmand has been rising. As evid-ace of thechanging official environment. the Government requested IDA to undertake apopulation sector review in 1984. The results of the review were dilcucsedat a seminar held in LilonVu. attended by senior Government officials.

2.50 The first MDA-assisted health project began in 1983 and focused onhealth planning and financing. The project's objective is to make thehealth system more responsive to the health needs of Malawians. Zach of thefive components deals with major pr',blems identified in the 1980 HealthSector Review: a comprehensive National Health Plan; an improved ploaning.monitoring and evaluation capacity, and improved systems of financialaccounting and health and service statistics; an epidemiological surveycapacity; an efficient, cost-effective system of pharoaceutical procurementand distributioun the first phese of a natiaonl priary health care program;and the introduction of child spacing activities. The National Health Planhas been completed. A Co mnity Health Sciences Unit (CHSU) to improvemonitoring capacity, undertake epidemiological surveys and strengthen healthstatistics collection is being established. Training of staff inbiochemistry, microbiology, and laboratory techbology has been delayedbecause of difficulties in obtainiug admission into oversea universities.Substantial progress ha been made in the pbhrmaceutical component. The CRSwas established as a distinct self-accounting unit with effect from April 1.1984. Facilities for anufacture of drugs at Blantyre are in use. Mostprioary bhalth care activities have been completed abead of seb dule, and inmost caes agrod targets have been meoeded. The sac situation prevailswith regard to child spacing activities under the project. The ongoingproject ba emphasised cost-effectiveness (through strengtbening the CXM),cost recovery (with the introduction of fees for some categories of services(pares. 2.39-41). strooger comnity involve mt (through the PlC program(paras. 2.33-34). consolidation rather than expansion of bealtk facilities,ad institution building (through strengthening the planning process andestablisbeet of improved systems of financial accounting). Thesestrategies are comprehensively reflected ln the National Health Pln (par"s.2.13-2.14). A review of financial system bs been completed.laplementation of rccinendations in this review will continue in the

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proposed project. Despite these achievement the project has lagged behindwith regard to civil works and has been extended by two years.

S. The First Phase of the National Health Plan

2.51 Following approval of tho National Health Plan (1986-1995), theKOH prepared a comprehensive implementation program for the period 1986-1990. The progran was appraised by MA in December 1985. It wa agreedwith the Government that a phaed approach would be followed. The firstphase will cover new activities initiated during the first thre years andthe second phase will include activities to be initiated during and beyondthe subsequent two years of the proposd progrm. The investment costs forthree years activities would be US$ 43.0 million. Out of this planactivities amounting to US$ 22.9 million are to be finaneed by the proposedIDA-financed project. Using tbh Bank's standard disbursement profile forMalawi this works out to US$ 24.9 million. Details of the investment planare provided in Annex 1 Table 12. During negotiations assurances wereobtained that should the Borrower propose to make any investment in thehealth sector which is not included in the first five years of theBorrower's National Health Plan (1986-1995), such investment shall be madeby mutual agreement between the Borrower and the Association (par&. 7Olb).

2.52 During the first phase of the Plan the following components willbe implemented in the MOH: (a) increased coverage of peripheral anddistrict health services; (b) manpower development; (c) management andsupport systems; (d) fasily bealth; (e) disease prevention; and (f)nutrition activities. A sulti$ectoral family health program comprising thefollowing components will be implemented through other ministries: (a)functional literacy and women's programs; (b) youth programs; (c)informotion, education and communication activities; (d) census support; and(e) establishment of a population planning capability.

2.53 The Governmnwt invited donors and IDA to participate in thefinancing of the first phase of the Plan and organized a donor conference inMalawi in September 1986. Donor agencies supported the principles andstrategy of the plan and a number of them indicated strong interest insupporting specific activities or program. inncing for over 502 of thefirot phase has been agreed to. UNICUP has formally agreed to finance theezpmaded program for imunization in its entirety. The Federal Republic ofGermay indicated strong interest in financing the Zomba General Hospitalsthe Iachinga district hospital and the bilhar$ia control program. UNPAindicated its interest in financing the component on the establishmont of apopulation planning capability in the IP and D. USAID hs boen supportingenvironmental bealth activities and has funding coiitted until 1989. Forits next round of assistance USAID ozpects to continue support forenvlronmentsl health and diarrheal disease progra s. USAID has beonproviding contraceptives required since the inception of the child spacingprogram. A satisfactory system for ensuring continuity of adequate supplieshas boen developed. The complete range of contraceptive supplies (except

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injectablec) is being provided by USAT. Injectables are provided by UNYPA.Arrangements for the supply of contreceptives for the envisaged expansion ofthe child spacing prograa are considerd satisfactory in the foreseeablefuture. In addition to these free standing activities/components, EDY,UNICU. UNFPA. KfW and the Government of the Netherlands are planning tofinance activities which are inter-linked and are described as part of theproposed IDA-financed project.

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III. THE PROJUCT

A. Objectives and Desmig

3.01 The proposed project is an integral part of the first phase of theNational Uealth Plan. It will complemnt activities finaced separately bydonor agencies (per". 2.51-2.53). The objectives of the project are to:

(i) improve health status of f$milies particularly of nothers andchildren through expansion and strengthening of ezisting healthprograms

($i) increase the availability and accessibility of a complete range ofchild spacing services within the MOM's MCR program;

MOii) strengthen the NOR's capacity to plan. mange nd evaluate healthservices in the framwork of a d centralized health system a nd

(iv) design and implement a multi-sectoral fanily health programthrough other government agencies.

3.02 The proposed project is a logical follow-up to the IDA-assistedfirst health project. It is designed to continue institution buildingactivities, to consolidate and ezpand PHC and cbild spacing begun under thefirst project, and, to introduce fasily health activities through a multi-secteoral approach. The project would support activitieos implemented throughthe NOE and otber ministries. Through MOR it would finance activities at thenational, regional, district and peripheral levels. At the peripherallevel, it would improve coverage of health services. At the districtlevel, activities would comprise: MOR management and support systemstrengthening, provision of surgical contraception services, andstrengthening of district level referral services. At the regional level,activities would focus on management strengthening; at the national levelactivities would includet management and support system strengthening,manpower development, training and IIC in primary health core, child spacingand nutrition programs, and urban family health services. To promote familyhealth multi-sectorally using other goavrnmnt ageicies, the project wouldsupport IZC snd training activities in functional literacy, women's andyouth programs; and the development of INC campaigns on femily health.

3.03 The Government has established the following targets for the five-year period:

(i) reduction of IMR from a national average of 151/1.000 to 100/1000live births;

($i) reduction of 0-4 cumulative mortality from 330/1000 to 210/1000live births;

($ii) reduction of maternal mortality from 16/1000 to 10/1000 births;and

(iv) achieve a contraceptive prevalence rate of 102.

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These targets are ambitious and the mortality reductions are unlikely to beachieved in the short space of 5 years. although substantial progress shouldbe possible. onitoring and evaluation studies are plannd (see belowpars. 5.07 and 5.08).

S. Suomary Description

3.04 The project, designed to be impleaented over a three-year periodstarting April 1, 1987. eonsists of two parts: Part A. to be implemented bythe MM, and Part B, which comprises multi-sectoral family health activitiesto be impleeonted by various government agencies and coordinated by BP andD.

3.05 Part A includes the following three components:

(a) Primary Realth Care (US$7.6-)1, The expansion of the primryhealth care program from nine districts at present to cover sixmore districts including training, provision of equipment andsupplies for village health comittee; construction. furnishingand equipping of 19 new health ceters and upgrading of sixexisting health sub-ceoters; and replacement of one mzistingdistrict hospital.

(b) HMaaemnt, Manpower and Support Systms (U!43.3a). Thestrengthening of the management of NOM through technicalassistance, workshops and training at all levels of the healthsystem; the replacment of an existing enrolled nurses school;construction, furnishing and equipping of three regional leveltraining facilities, and of pharmaceutical depots at eightdistrict hospitals; equipping the NOR and major hospitals withcomputers for budget management; equipping of a quality controllaboratory; baseline, monitoring and evaluation studies, and astudy of the potential of health insurance.

tc) Family Health (US$5.8a). Strengthening the MCR program throughtecbnical assistance, training, provision of Information.Iducation a*d Comunications (IZC) vaterials, vehicles andequipment. Strengthening of the child spacing program byorienting all health staff and training 900 service providers,construction of surgical contraception units at seven districthospitals, construction, equipping and furnishing of three newurban health centers and replacing a family health unit inLilongwe. Strengthening nutrition activities in the MOR throughtechnical assistance, development of ric materials and trainingbealth workers.

(d) Project Management for Part A (US$1.5n). Salaries of a projectcoordinator, technical advisor, clerk of works, procurementofficer, sceountant, support staff of administrative assistants

1 Costs excluding contingencies.

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and secretaries, and office equipment and supplies; andpreparation of a third project.

3.06 Part B includes the following three components:

(a) Functional Literacy. Nutrition and Women's Proutrms (US$3.3m).Under the Ministry of Community Services (MOCS), introduction offanily health topics into ongoing functional literacy and women'sprograas and expansion of these prograns to the Northern Region;construction, equipment and furnishing of a regional trainingcenter, production of IEC materials and overseas and localtraining; the establishment of nutrition activities in the MOCSthrough training women's groups and community developmentassistants (CDAs), strengthening nutrition-related activitiesthrough surveillance, and nutrition education, and construction offish ponds.

(b) Youth Programs (US$0.4.). Under the Departsent of Youth.introduction of faaily health aimed at young audiences throughtraining, educational programs, equipment. IEC materials andinnovative activities.

(c) Information, Education and Communicgtion (US$0.6a). Developmentof notionvide IEC programs by the Information Department throughproduction of IEC materials, overseas training and surveys andevaluation activities.

C. Detailed Description

Part A

Primary Health Care

3.07 This component would aim at increasing coverage of peripheralhealth services and strengthening district health services. The projectwould support the expansion of the PHC program from nine districts atpresent to 15 districts. The pilot PHC approach dteveloped and tested partlyunder the MDA-supported first bealth project and adopted by Malaiw has beenevaluated (parsa. 2.33-2.34) and, with suitable modifications, will beexpanded in this second phase to cover six more districts. Training VillageHealth Committees (VHC) and bealth staff, provision of equipment andsupplies, increased supervision by health staff, and establishment of areferral network are the elements of Malawi's PHC program. Village HealthCommittees (VHC) will continue to undertake activities in sanitation andwater supply, maternal and child core and treatuent of common diseases. Inaddition, the MOB has recently decided to provide child spacing servicesthrough VHCs.

3.08 The project would support training activities for V8Cs and healthstaff including workshops and seminars for senior district officers, *mebersof District Development Committees (DDC). district and area PHC tea" membersa*d TICs annually. A sajor effort would be initiated through the project to

- 25 -

have refresher training for VHCa and health staff on a regular basis.Details of training activities are presented in Annez 1, Table 14. Theproject would also aupport visits by health workers from project area tostudy the success and difficulties being faced in the implementation of PHCin other areas. Area level PHC staff would visit other areas within thesame district (three visits per district annually). District level PHCstaff would visit other districts where PEC activities are being isplemented(one visit in each region annually). Such training activities will be takenup in two districts every year and thus in siz districts during the projectperiod. In addition, intensive retraining is proposed for three of thefirst phase districts over the project period; each year. based on anevaluation of the PHC program, out of the nine districts in the first phase.one district will be selected for retraining. Training activities for PHCwere first developed under the IDA-supported first health project.Following an evaluation, these courees have been suitably modified. Thecourse content is appropriate, and training methods are consideredeffective. Details of the training activities to be undertaken under theproject are available in the project file. Also, the project would financeabout 400 drug kits for VHCs, at the rate of one kit per VHC annually. Toimprove the ability of health staff to supervise VHCs the project wouldprovide 48 motorcycles and 300 bicycles, financed in parallel by UNICEF.

3.09 In each area where the PHC program is implesented a health centercapable of providing support for village level activities and for acting asa referral facility is required. Six ezisting health sub-centers needupgrading to health centers. Nineteen new health centers also need to bebuilt during the project period. Nine of these centers are to be located inthe six districts (namely Nkhata bay, Lilongwe. Chiradxulu, Rumphi, Kasunguand Kangochi) where the program is being extended into its second phase.The other ten centers are to be located in the nine first phase districts(namly Mzimba, Dowa, M?anza, Mulanje, Dedza, Ntcheu, Karonga, Chikwawa andNsanje; see map for details). The need in the first phase area is toconsolidate the health infrastructure, based upon the experience of the lastfew years of the PHC program. Each health center of approimately 400m2

would serve 10,000 persons. In each new center the project would financethree houses for two enrolled nurses and one medical assistant, and onebouse would be added at each upgraded health center. During negotiationsassurances were obtained from the Government that the health centers, oncecompleted, would be adequately staffed by at least one medical assistant andtwo enrolled nurses (par&. 7.01 c).

3.10 Health centers refer patients to district bospitals. In Malawi, anumber of district hospitals function in inadequate, old buildings. Bedoccupancy rates, however, are very high (Annex 1, Table 3). Overcrowding iscomon. With the implementation of PEC prograas and the introduction ofchild spacing services at the district level and below, the role of thedistrict hospital hc become even more crucial. The project would supportthe replacement of one existing 102 bed hospital at Mzimba. The newfacility with a total area of about 4500W 2 would have 40 additional beds andspace for surgical contraception. The hospital is now heavily utilized andits current bed strength is inadequate for the demand it faces. Preliminarydrawings have been reviewed by IDA and recomendations for nodificationshave been made (par&. 5.01). In addition to replacement of the existing

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hospital, provision is made for 20 staff houses for key staff who need tolive near the hospitals. Mzimba hospital and housing would be constructedon a nw site which has been acquired. The existing facility would beturntd over to the 'istrict authorities. The hospital would be providedwith two ambulances and one station wagon.

Management, Manpower and Support Systems

3.11 Management. This component would aim at strengthening themanagesent of health services at the national, regional, and district levelsby restructuring the MOH and improving systems and procedures. At thenatiopal level a study of the MOH by the Malawi Civil Service ReviewCommission has revealed the need to revise the organizational structure tomake it more responsive to the changing needs of the health sector (paras.2.21-2.22). Restructuring of the MOH headquarters would require functionalrealigmnent of departments, creation of a manpower coordination unit, andreview of the layers of authority in the administrative branch (Chart 2). Atime bound plan for reorganization of the MOH is being developed and will beadopted by the Fall of 1987 (para. 2.22).

3.12 Detailed management studies of each unit of the health caredelivery system have been completed by the Malawi Civil Service ReviewComission. Additional studies are being undertaken by the MOH with fundingfrom the first IDA-supported health project. The project would continue theprocess of strengthening the management of MOH by developing unit and jobdescriptions, and a short-term consultant would be provided to assist withthese studies. After finalizing unit and job functions, national, regional.and district workshops would be held to train health staff in management andnew procedures. A national five-day workshop for 25 unit heads and programsmangers would take place annually. A four-month consultancy would beprovided to develop curricula and plan the seminars. The project would alsofinance three one-month study tours to neighboring countries for senior andmiddle-level MOH officials annually.

3.13 The project would finance the establishment of a regional healthteam in each of the country's three regions, which would back up andsupervise the health services of the region. Each regional health teamwould comprise a Regional Health Officer (team leader), a regional nursingofficer, a regional public health nurse, and a regional public healthinspector. The project would finance three regional health officers andthree regional nursing officers, three drivers, and would provide threevehicles (one per regional health team). During negotiations, assuranceswere obtained from the Government that posts of three regional healthofficers and three regional nursing officers would be created and filled byOctober 1, 1987 (para. 7.01 d).

3.14 A major area of concern is the management and administration ofhospitals. Detailed studies of the two central hospitals have been carriedout by consultants financed under the first IDA-supported health project andrecommendations have been made to improve overall efficiency. According tothese studies up to 40t of non-personnel costs at the hospitals could besaved through better management. The project would support annual workshopsin hospital management and administration for all hospital secretaries and

- 27 -

administrators in Malawi. During negotiations the Government submitted animplementation plan for cost reduction measures satisfactory to IDA. TheGovernment has agreed: (a) to establish within MOH, not later than July 31.1987, a committee with the Deputy Secretary of the MOH as chairman withrepresentatives from the Queen Elizabeth Central Hospital. the KamuzuCentral Hospital and the Zomba General Hospital to monitor theimplementation of cost reduction measures; (b) to implement cost reductionmeasures at MOH and at the Queen Elizabeth Hospital by December 31. 1987;(c) to submit to IDA by March 31. 1988 for its review and comments, anevaluation of the cost reduction measures implemented by MOH; (d) toimplement cost reduction measures at the Kamuzu Central Hospital and theZomba General Hospital by April 30, 1988 and at all district hospitals byDecember 31. 19881 and (e) to decentralize finance and accounting functionsof the three major hospitals from MOH to the Queen Elizabeth CentralHospital, the Kaauzu Central Hospital and the Zomba General Hospital by notlater than April 30, 1988 (para. 7.01 e).

3.15 The Planning Unit was expanded and six new posts were establishedthrough the first IDA-assisted project. With the development of a NationalHealth Plan (para. 2.13) and training in planning of senior Planning Unitofficials, the MOH has developed an increased ability to plan and evaluateprograms. The Planning Unit has evolved into an effective organization.The project would support the MOH's efforts to further improve its planningcapability, through increased emphasis on decentralization of the MOH andby strengthening district level planning capability. A seniorinternationally recruited health planner was appointed in 1986 and has beguntraining district level staff. The project will provide for one long-termand one short-term training course in health planning and one five-dayworkshop annually for 20 senior officials to assess implementation of theplan and to recommend modifications in strategy. A study of the impact offees charged on utilization of services and on the potential for healthinsurance would be undertaken by the Planning Unit with assistance of ashort-term consultant.

3.16 The project would finance an expenditure control accountant at thecentral budget section, three regional level accountants and one accountantat each of the three main hospitals. Also four computers needed to improvefinancial accounting would be financed (one computer for the MOHheadquarters and the remaining three for the main hospitals in Blantyre.Lilongwe and Zomba). During negotiations assurances were obtained from theGovernment that the positions of one expenditure control accountant at theMOE, three regional accountants, and one accountant at each of the majorthree hospitals would be filled by October 1, 1987; in order to carry outcost reduction measures at district-level hospitals, the Government hasprovided assurances that it would hire assistant accountants for each of the21 district hospitals by August 31, 1988 (para. 7.01 f).

3.17 Manpower. The project would provide for: (a) strengthening thecapacity of the MOH to train enrolled nurses; (b) establishing an in-servicetraining capacity; and (c) developing MOH's capability to undertake manpowerplanning and analysis. Project assistance would include construction,furnishing and equipping of one school for enrolled nurses, hostel and

- 28 -

warden's flat at Zomba, with a capacity for 140 students (about 4000m2), tobe built near the Zomba General Hospital at a mite already acquired. IDAhas reviewed sketch drawings and suggested modifications (para. 5.01). Theproject would improve in-service training by MOR of about 1.000 healthworkers annually by financing construction, furnishing and equipping ofthree regional level training facilities (each of about 400sq.m area andincluding one house for the resident caretaker). Courses to be offered atthese facilities are described under the respective MOH programs.Utilization rates are expected to be 952 during the first three years and852 in subsequent years. Sites have been identified and are being acquired.Sketch drawings have been reviewed and considered satisfactory. To ensuresatisfactory scheduling of training, the appointment of a Training Officerwould be essential. The project would also finance the overseas training ofa middle level officer in manpower planning for one year. Duringnegotiations assurances were obtained from the Government that a TrainingOfficer would be appointed by September 1. 1987, to coordinate in-servicetraining activities; and that in-service training plans for the GOM fiscalyear beginning April 1988 would be submitted to IDA for review and commentby December 31. 1987. with annual plans for succeeding fiscal yearssubmitted by December 31 of the previous year (par. 7.01 g).

3.18 Support Systems. With the establishment of a Community HealthSciences Unt in 1984 the MOH began to develop a capacity to undertakesurvey and evaluation activities. The project would support the MOH'sefforts to further strengthen its monitoring and evaluation capability. Abaseline health status and utilization study would be undertaken in thefirst year of the project, with a survey planned in the third yea-. Theproject would provide a short-term consultant for one month in the first andthird years to assist with study design and field work. In addition, therewould be annual impact studies of specific programs.

3.19 Efforts to improve the effectiveness and efficiency of thepharmaceutical system were begun in 1983 (para. 2.23). The MOH proposes tofurther strengthen the pharmaceutical system by decentralization down to thedistrict level. The project would finance the renovation of pharmaceuticaldepots at eight district hospitals including furniture and equipment, andthe establishment of a quality control laboratory. Through 28 man-months ofconsultant services the project would support the drafting of druglegislation, review production procedures at CMS, review quality controlprocedures and computerize CMS operations. There would be two seminars ofone-week duration for 20 pharmacy assistants in the scope and functions ofthe revised CMS and two five-day annual seminars each for 30 drug pre-scribers. The project would also finance 25-1/2 months of overseastraining in drug inspection, drug administration, quality control and drugmanufacture.

Family Health

3.20 This component would include: (a) maternal and child health(antenatal, natal and postnatal services, and health services for underfives); (b) child spacing; and (c) nutrition.

3.21 MCH. The progrum is hampered by poor and inadequate transport,lack of IEC materials and shortage of drugs, and has weak postnatal services

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(part. 2.29). The project would finance the replacement of 27 vehicles forthe regions and districts, for service supervision and for the provision ofmobile services. Maintenance facilities at the regional and district levelsare considered satisfactory. Two boats to provide MCH services to islandand lakeshore communities would be financed. The project include one monthconsultancy for the development of an integrated course in family health for200 health workers annually; annual in-service training in priority diseases(diarrhea, malaria, respiratory illness, measles, and nutritionaldeficiency) for 900 health workers; an MCH manual for use by health workersin MOH and PHAM units; printing of IEC and training materials developed forthe MCH program; and annual supplies of drugs for 1.100 MCH centers and 639antenatal clinics. Through the proposed training activities emphasis wouldbe placed on the development of postnatal services (pars. 3.22). Theproposed content of courses has been reviewed by IDA and is consideredappropriate. Details of the training activities are available in theproject file.

3.22 Child Spacing. The enhanced receptivity towards child spacing hasled MOR to increase the range of services offered and to make servicesavailable more widely (paras. 2.30-2.32). The project would assist indevelopment of surgical contraception services and expansion of urban andrural family health services by training of health staff. TBAs and VHCs inchild spacing and printing of IEC materials for child spacing. The projectwould finance the building, furnishing and equipping surgical contraceptionunits at seven district hospitals. Designs for the units have been approvedby IDA and the list of furniture ard equipment finalized. The project wouldprovide a one month consultancy to review training and quality controlplans. With increasing demand for child spacing services in urban areasthere is a need to provide adequate facilities (pars. 2.32). The projectwould finance construction, furnishing and equipping of an urban familyhealth unit in Lilongwe, three health centers in Blbntyre and Lilongwe, andupgrading two existing health centers in Blantyre and Lilongwe. Designshave been reviewed and modifications suggested for the family health unit inLilongwe (para. 5.01). The project would finance the training in childspacing of 20 trainers, 10 tutors, 675 nurse midwives and enrolled nurses,225 clinical officers and medical assistants; the orientation of 1,440health personnel and 1,500 DDCs and VHC members in child spacing. Thesetraining activities were introduced initially under the first IDA-supportedhealth project, and are considered appropriate. Details of the trainingactivities are available in the project file. The importance of thepostnatal period both for better mother and child care and for provision ofchild spacing services would be emphasized in these courses (para. 3.21).IEC materials would be financed by the project as would the appointment ofsix clinical officers and 16 enrolled nurses for the urban family healthclinics. During negotiations assurances were obtained that six clinicalofficers and 16 enrolled nurses would be appointed to the urban clinics oncecompleted (para. 7.01 h).

3.23 TBAs would be trained in child spacing under the project. Fourcourses, each for 15 TBA trainers, would be undertaken during the first twoyears of the project. (A TBA trainer is an enrolled nurse posted at ahealth center and trains about five TBAs in her area annually.) About 250TBAs would be trained per year in child spacing.

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3.24 Nutrition. New initiatives in nutrition are being proposed by theMOH with the participation of the MOCS to deal with the problem ofmalnutrition and the consequent impact on infant and child mortality. Theproject would promote nutrition education through MOM and growthsurveillance at health clinics. These activities would be undertaken inconjunction with the MOCS (para. 3.27). The project would include thedevelopment and production of flip charts, posters and post literacybooklets for use by the MOH through health clinics. Health workers would betrainied in nutrition as part of the family health training program (para.3.26). To develop nutrition activities further, particularly with the EPand D, the project will provide two man-months of consultancy.

Proiect Management

3.25 The project would provide for a project coordinator, technicaladvisor, clerk of works, procurement officer, accountant, support staff ofadministrative assistants and secretaries, and office equipment, suppliesand a vehicle. Funds for the preparation of a third project would also beprovided. The project coordinator would report directly to the Chief ofHealth Services, MOH. A project coordinator has been appointed under termsof reference approved by IDA.

Part B

3.26 Part B of the project would finance family health activities to beundertaken by government agencies other than the MOH, including nutritionactivities to be undertaken by MOCS, complementary to the nutritionactivities to be undertaken by MOH (para. 3.24). These activities would becoordinated by the EP and D.

Functional Literacy, Nutrition and Women's Programs

3.27 The 1977 Population Census revealed that 82.2% of the populationof all ages was still illiterate. Of these, 77.5% were in the economicallyproductive age of 15 and above. The widespread illiteracy in rural areashas constituted one of the major limitations in enhancing the pace of ruraldevelopment. The Government has therefore set the target of achieving twomillion literate by 1990. The strategy is being carried out largely throughadult literacy classes held at the various functional literacy centers. Theprogram is well managed, and evaluations have shown that it is effective.However, up to now, this program has not dealt directly with matters ofpopulation education or family health. Through the Functional Literacycomponent the proposed project would introduce family health into thecurricula and would finance designs and production of written/pictorialmaterials.

3.28 This component would aim at rapid dissemination of messagesregarding family health to both the rural and urban population. Thoughchild spacing topics would have priority, nutrition and maternal and childhealth services would also be covered. Through this approach, it is

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ezpected that the demand for child spacing and family health services wouldbe stimulated. tll adult literacy centers would receive informationrelating to family health. The target audience will be the large andgrowing number of illiterates, both men and women, field workers and youth.in both urban and rural areas. Materials to be produced would includeliteracy booklets, family health booklets, posters, and flip charts. TheMOH would review all materials produced by the MOCS. which has thecapability to undertake these tasks. Training activities under the projectwould include: courses on family health for Members of Parliament (MPH),Home Craft Workers (HCWs) and their supervisors the Community DevelopmentAssistants (CDAs). The basic function of the latter two cadres is thepromotion of women's welfare; they are controlled by MOCS. Refreshercourses on family health would be held for HCWs, local women's leaders,functional literacy educators and literacy supervisors. Details of thesecourses are presented in Annex I, Table 14. The project would finance theconstruction, furnishing and equipping of a training center for the NorthernRegion to enable the courses discussed above to be carried out regionally.This center would serve the needs of the MOCS. The project would finance 10study tours of one-month duration by planners and program managers from MOCSto study the operational aspects of similar successful programs in adultfunctional literacy and women's activities in neighboring developing beundertaken through MOCS: training women's groups to undertake nutritionsurveillance and related nutrition education and introduction of fish pondsto provide protein for mothers and children at the village level. Theproject would finance the development and production of IEC materials,training CDAs and the construction of fish ponds iD 150 village communities.Fish froa the ponds would provide much needed protein for mothers andchildren. Technical assistance for construction and maintaining the fishponds would be pro-vided by the Department of Fisheries, which has hadconsiderable success in smi 1 scale fish farming in Southern Malawi. Duringnegotiations assurances were obtained from the Government that the MOM wouldestablish by September 1, 1987 a health information, education andcomMunLation review committee to approve IEC measages prepared by non-MORagencies chaired. by the Chief of Health Services with members fro* theMinistries of Health and Community Services end the Secretary for Youth andthe Malawi Pioneers (pars. 7.01 i).

Youth Programs

3.29 Youth between 13 to 19 years of age are an important target groupfor family health education activities. The Malawi Young Pioneers (MP?)program trains yout! in this age group in a number of activities bothtechnical and non-technical. However, issues related to tamily healtheducation are not included. Malawi youth in this age group are notadequately provided with information needed for their fertility regulation.This contributes to unplanned pregnancies and very often an increase in thedropout rate from school.

3.30 The objectives of the youth program component would be to:provide MYP matron/instructors/instructresses with knowledge related tofamily health education, to be in turn imparted to MYP youth; provide femaleMYP graduates with knowledge related to family health education so as toprepare them for responsible adulthood; and equip MYP graduates with

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sufficient knowledge and skills that will enable them to informally educctefamilies and fellow youth in their respective communities.

3.31 The project would provide training programs in family health for100 MYP matrons, instructors and instructresses. basic training courses forfemale adolescents (13-19) and young women (20 and over). Details of thetraining activities are presented in Aunsx 1 Table 14. The project wouldalso include the construction of 10 simple shelters attached to existingdispenaaries to be used by MYP volunteers to educate women coming to thedispensaries. The project would support the provision of one sewing sachineto each of the 49 MYP youth clubs and one fish pond in each of the sevERn MYPbases in the country for demonstration of potential income generatingactivities to village comunitieu. The introduction of income jeneratiugactivities, particularly to women, has been demonstrated to reducemorbidity, mortality and fertility.

Information, Education and Communication

3.32 The objectives of the ISC component would be to enhancereceptivity among the people of Malawi to the concept of fasily health andto update knowledge regarding family health among service providers. Theprimary target audience would be: the rural population, men, women andyouth; local leaders and traditional authorities; urban population, men andwomen and youth; and health service providers.

3.33 The IEC component would be primarilv concerned with the expandeduse of ass *edia in support of fsaily health activities and boldingtraining/refresher workshops to further sensitize existing health merviceproviders and others associated with the content of media messages andmulti-media use. The activities would be implemented by the InformationDepartment, Office of the President and Cabinet. The project would enablewidespread use of the mass media through introduction of family healthmesoages into the Chichewa paper, Bona Lathu, to reach a monthly audience ofebout 500,000; family health boards on long distance buses; family healthlabels on match boxes; radio programs on family health; and production oftwo 20 minute films annually. The project would include overleas trainingof three Infornation Department staff in graphics, audio-visual techniquesand development c%mmunications. The MOR would review the content of fasilyhealth messages developed for use by other ministries (pars. 7.01h).

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IV. PROJICT COSTS AND FINANCING

A. Costs

4.01 Although the project has been designed to be impleewnted over athree-year period, it has been cated over a five-year period, to have adisbursement profile corresponding to the standard profile for Malawi.Total costs of the proposed project are estimated at K56.1 million (US$24.9sillion equivalent). Base costs are calculated at US$22.5 millionequivalent (902) and contingencies .t US$2.4 million equivalent (102).foreign exchange costs account for US$11.6 million or 47Z of total projectcosts. Taxes and duties have been calculated at US$0.4 million for civilworks, design fees, furniture, materials, equipment and vehicles. Projeetcosts by expenditure category are summarized in Table I below, and detailsare provided in Annex 3. Capital costs for civil woris account for 432 ofbeae costs; furniture, equipment, vehicles, supplies and saterials for 22Z;monitoring and research activities 1; technical assistance for 72; trainingfor 152; and incremn tal recurrent costs (salaries and allowances, building.equipment and vebicle operation and maintenance) for 92.

atoe 1: ProJoct Coot. by Expenditure Cataliry

., 411~SE FIWILY "XIN ""CTSIT ACfOiL MT MalC

a.il C.r , or , (u 459 OR,

;-~~~~~~~~ ;.;.3 . .3"s 9.,. : For,na.l S.,,

* J j.4iIe,z 'AL, E^e* Sar =.id su'Iak '4ti,d E.cftMi* 3.411...... .. ;.,; . ... .. .... . ............ ,,;..---........ .. . . .

.. A$14EN1 C05TS.. ..... ..... *@6....

A. CIVIL MS .'1'. 1 '743.0 19,442,6 40 43 5.4.S ;31..5 9.7:; S. FUM3T 302 3 405.0 4,217:3 3 402 :4: 5 ,3.* ; i 7

M A0TERIALS Il ? . ,* 5.948. '0 43 M9 2 '@.S ''070.3 I ''D ENUPIM 47I 1,3 ,39.3 I 334 , 99 3 8. 844,7 a?3. nE. 4AICLS 13.9 i.394.3 1- .: 3 ,.9 01 *04. ir. TEhlEliL WSIsTU 3y ,1:9.1 379.1 0 -10379,. W 4Mt6. KOIS FEES 1,217.3 1,17.0 1 1 .43. 043.' 3.. 4131135 , l J . EJIllIlR 47.E - 4754 - 237.7 :3i. ATIVITIES -* 71 - 4.4 4.0

TRAWN .:,14.: 5 - 0142.1 14 3.071.4 3.80,1.4a, Mfl1W 1040IMIN - 453.3 453.3 4O4 4 - 2.A 2i.' : :

Toll INKSM!T WiATS A,..2 M13.6 41,043.i 4 71 II,I3.I ..3' 20,30, 4, '3z,ca4 ~.t4rwud,,, s,434.2 1,510.3 7'4.5 51 '11. 7S3.: :Z413.3Price Cobt&t swn 43743.2 3W .1 .3111.0 44 33 414.' 341.7 '43.4 4.

........ ..... ... . _...... ... .... . .... ... _...... .. .... ...... ....... .. .. .... ... .. .... ....

?@UI ligL.lilS CWITIES 7440.5 23,171.1 50,539 3 44 111 12,270.t 10,471, 22742.3 4 ,,,,,,,,,,...... ........ ......... ...... ........ .,...... ,........ ........... ,.i

43 410W colS. ....... . . _...

A. IS.WIE 1.44.' - .4444. 3 723,2 - '23.I., I 9X t I 2Ii e tliTtiw aA. 1,i. 322.: 40 3 154.0 40'.4 'w1 10 ;C. lSIl M1U?Ul O 44.4 334.) 499,7 Z 0 20.2 7., 94 i :S. N L8Z4SIN its" is 12 f iln, 3W.2 4t591 'S

.. .... .... .... _... . ... .. ._... .. _. _ .... .. .. _ ..... .... ... . .. ............... .......

Toel mt C1tS I'M.$ 24.9 4.t 177' 52 '15.41-0'53.5 2,043.T 5IP9.s,e,4 C.tier_4.1 47 4 64.7 Si, I K 1.' 34.4 43.1 0 ;Fn C.1&r_ Hin 493.3 1 42.9 1,056.' 53 2 52.13 59,4 il:.8 53 o

Ytill SS.0C51ttl1E IS 249,2.0 2-''.3 5-2333, 52 12 14045.3 I,147.2 .:91, S; 5

.1.3 .LMS TITS 24257.0 ......2.. 4309 4 4 .. . 2. 21.3.0.424,3 22 .4... ... .W'fewat,c Un -<in3. 1-45 3 ,0 3,032.4 52 '26eO 'Ps.3 :4514.3 5SPrien C.t0 _ema , $,442.0 3-,95.7 7,M.' 4? I 467.0 403 , I'S,: I ' 4

l1,4A ISfT CWITS 2q,932.* 24,447.3 540-9.1 47 :24 1-3Zl,3 1-,11.7 4,14.94, 4* il;

-3 lff* -A...a £8..33..8 £*lS. ................................. ~

- 34 -

4.02 Project costs have been estimated at December 1965 prices updatedto January 1987 price. Civil works costs have been estimated on the bsisof the value of current Ministry of Works and Supplies contracts forcomparable buildings whether locally or ezternally financed. The designsare considered to be appropriate and cost effective. Purniture *adequipmant lists hve been dram up. Project costs also include provisionfor a total of 41 four-wheel drive vehicloe, at a unit cost of aboutUS$14,800 (on CIY basis) and other vehicles (48 motorcycles. 300 bicycles. 2boats) totalling about US$184,200; 144 mths of overseas training, at anaverage monthly cost of about US$2,500; 92.5 months of long-term foreigntechnical "aistance sad 23 moths of foreign short-term technicalassistance. Incremetal salaries, local training costs and operational andmaintenance ezpenses are bsed on current Governmt scales and rates.

4.03 The total project costs include Us$2.4 sillion equivalent forcontingeniees. Physical contingencies have been included at 10 for civilworks and 102 for vehilels ad equipment, and comprise US$1.5 millionequivalent (72 of base costs). The following price contintgecies have beenincluded: (i) on foreign exchange ezpenditures. 122 in 1966, 32 in 1987, 12in 1988, 1S in 1989s 12 in 1990,; 3.52 in 1991; and 3.5 in 1992, and (ii)on local cost expenditures, 132 in 1986, 102 in 1987, 82 in 1988, am 62 in1989 sad 6S every year thereafter. Price contingencies account for US$0.9million equivalent or 42 of base costs. It is expected that the exchanerate will continue to be adjusted to reflect the difference between dowsticand international inflation.

4.04 The foreign exchange component of US$11.6 million equivalent isbased on estimates of 4O0 for civil works; 382 for furniture; 992 forequipment; 1002 for technical assistance; and 1002 for overse" training adstudy tours. The incremental recurrent costs involving foreign exchange(102 of foretign exchange) mainly cover equipment and building maintenanceand vehicle operation an maintenance.

4.05 Project costs by functional component are shown in Table 2.Primary bealth care would absorb 342 of base costs; management and manpowerdevelopsent and support systems 1S5 fouily healtb program 262; projectmanagemeat 72; functional literacy and women's programs 152; youth progras22S and ISC activities 32.

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KCUSE FUNILY "ELTN PROJECTTable 2: Proiect Costs by Functional Component

(Loxal Cutrwe 'M00 (U31 '000)

Totld TuW1. Foreign lse : Foreiv, Iai.

Local Foreign Totl Exchuw Costs Local Fcdeif. T%tal Exchmnge Coit.as5::: azss:gzza:zz :az z:z_::::s :ass:aat *,::s : : : = --

A. PR1VRI EALTH Ca

1. PRIWY HEALTH CAE Ue.3 138.4 974.7 35 ^ 318.1 1i9.^ 487.3 35 22. EXTENSIN OF ILAtN EMIMCS 5.152.4 3.754.9 G9p97.4 42 20 2,576.2 1,677.5 4,453.7 42 ^03. SKETITNENIE V THE NIPIML SYITER 31075.6 2P200.7 5.276,3 42 12 I1537.8 1,100.4 2e638.2 42 12

ib-Total P7IIY IMTN CAE tJ64.3 60.214.1 15M158.4 42 34 4P432.2 3r147.0 7,579.2 4: 343. NAuAENi t IVWa - 31 StITERS

1. NURS3I EIICATION 1,225.6 992.7 2,118.3 42 5 e12.6 446,4 1;059.1 42 5. ISEIEICE ThAINIS 487.3 340.9 828.2 41 2 .43.7 170.4 414.1 41 2

3. ESTMLINT OF Ml'EI CAlPCTY - 3i.4 36.4 100 0 - 10.2 16.; 100 54. IWPEEN OF NIMENT SYSTElltUWISION AN KRIEL 2.5 243.5 336.0 72 1 4e.3 121., 1e8.0 72 1

5. WETH .N lABEIe 39.8 85,9 1.5 I 68 0 19.9 42.9 62.9 as 06. FIMIlAL 71_11I1 54.6 179.0 765.6 3 : 273.4 89.5 382.97. WEMNTH S MATN 1 _IEET INfOWAT1ION 261.8 40.4 302.2 13 1 133.9 :0., 151.1 13 191. 31RU PUCTION S YPY S19.9 1I148.8 1o667.7 69 4 259.4 574.4 e3;.c .9 49S INTIIAUTI1 OF SER9ICES AT ESIULL LEWEL 315.5 156.9 472.4 32 1 157.S 78.5 : c 33 1

Sb-loatl 1 1 ENEiT I NMI AS SOUFT SYSTERS 3,526.2 3,124.4 6,652.7 47 15 1.764.1 1.5422 3,326.3 4, 15C. FAILY HEALTH

1. NTERJL MD CHILD "iLTN 817.5 20793.0 3,610.5 77 6 408.6 1,396.5 1,905.3 ,, 82. CHILD SPACIN6 4.909.4 2,492.7 7,401.1 34 16 :o454.2 1.:46.4 3700.o 34 163. NUTRITION , 10 162.6 415.0 577.6 72 1 6:.3 207.5 28a.9 ^ I

Sub-lotal FlILY K mTN 5986.5 5o700.7 11,59.2 49 :6 2944.3 ,9s50.4 5,914.6 49 263. ROJECT WIENENT FOR POT A

1. PROJECT M1f6E1NT 49S 2 29499.5 2tS93.7 8 3 , : 4. It24.4 1496.9 83a;

Sub-Toal PRIOJECT IWMNE T FOR POT A 495.2 ^.498.5 2993.7 83 6 247.6 lr:49.2 I496.9 63E. EAMTN TIH OTHER NINISTRIES

1. ITJIT1ON TOM INoI 1,376.6 432.2 1,606.8 24 4 846.3 216.1 904.4 24 12. FUlltIW LITERCY ( INEL VWN I 24960.0 1.S55.9 4.910.0 39 11 1I480.0 929.0 29406.0 3i 113. YTlM PIWI 780.4 105.8 98".2 !2 , 390. 52.5 443.1 12 24. IIFORVATION, EUATION

ANS CWMIUICAIION 363.6 631.0 1W194.6 70 3 161.8 415.5 597,3 70 3

Sl-otal K.TN T S OClM NINIIYS1UE 5,490.7 3,224.9 89705.5 37 19 2740.3 1.61.4 4t,5:.6 37 19

Total 3AELIIE COSTS 249257.0 0.8642.6 45,0t9.5 46 100 1.129,5 10P421.3 2;,549.6 40 IGOSP iacal Contingencies 1,453.6 I,579.0 3,032.6 52 7 726.6 789.5 1,516.3 5:rice Cw.tirwKinca 4,242.0 3,95.7 7,937,7 47, la 47.0 40Z.1 85.1 47 4

Total PROJECT COSTS 29,"2.6 26P117.3 56.069.9 47 124 133^22.3 11,619.9 .4,41,2 47, 111

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B. Financing

4.06 Of the total project costs of US$24.9 million, including tazeo endduties amounting to US$0.4 million, the Government's contribution will beUS$1.9 million (8S). which will cover 272 of the recurrent costs and 6S ofthe investment costs of the project. The remainder of investment costswould all be financed from external sources. Table 3 presents project costsby financing source. UNICZF and UNYPA have firmd up their cmmitment toGMK, the Government of the Netherlands has transferred a contribution toWHO, and 3DF and KfW have given indications of strong support. SDI isezpected to appraise its component by nd February 1987* The proposed IDAcredit of US$11.0 million would finance 442 of the total project costs andwould support: the construction and furnishing of 12 new health centers andthe upgrading of 6 ezisting health centers and esociattd bousings theconstruction and equipping of one district hospital and related housings theconstruction end equipping of the Zomba Scbool of Nursings the constructionend equipping of 3 regional health training centers; 27 vehicles and twoboats for the maternal and child health program; construction and equipping163 fish ponds; construction and equipping a regional training center atbu:xu; the managenmnt. manpower and support system component of the projeet(except the drug production and supply sub-component which ix being financedby the Government of the Netherlands through MON); production and printingmaterials for the functional literacy programs training activities for youthprograms; and, support for project *mangeent. UNICEF is providing US$2.6million or 102 of the total project costs and would support: the primaryhealth care program; equipment for the new and upgraded bealth centers;technical assistance, materials and support for workshops and trainingactivities for the maternal and child health programs technical assistanceand production of materials for nutrition activities delivered through theIOH and MOCS. UDF is expected to contribute US$3.5 million or 142 of thetotal project costs and would support: the construction and furnishing of 7new health centers and ssociated bousings training activities of thefunctional literacy program; and equipment, materials and monitoringactivities for the information, education and comunication program;salaries and building and equipment maintenance costs of the rural healthcenters and housing. [FW im ezpected to contribute US$4 1 million or 172 ofthe total project costs and would support: for the child spacing program.construction and equipping of the urban family health unit in Lilongewe, 7contraceptive and surgical contraception units and 3 new urban healthcenters, upgrading and re-equipping of 2 emisting urban beclth centers.technical assistonce to the surgical contraception prograa. and salaries andmaintenace costs; salaries of personnel and equipment and maintenance costsin the accounting sections of MOH, the 3 regional teams and the 3 sajorhospitali, the 21 assistant accountants in each of the district hospitalsand an expenditure control accountant; and the vehicle maintenance costs ofservices at the regional level and the MCH component.

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UWPA h. agreed to finance US$0.9 sillion or 3.5S of the total project costand is ezpectetd to support training activities. technical assistance andmterial production for the child spacing program.

lw--iSEcoD FWILY INEMTH PECT

Table 3: Project Costs by Financing Source

UNITED SATIlSIITMSTAL' FUID FOR IUTElETIOiL

UNITTED TIllS EClIIC FuEn 6W0Qu4T OF FWMATION U OPI.IET 06113 OFC KIS FM INEUL FUE VIETE II TIE NTIETLMMS iCTIVITIES 6S30CTI113 m.I Total

- --- --- ---------- -------------- ------ - --- ----- - -- Local (Encl. hties I_mt I _Amt I _IMt ; A.mt ; Amot ; Mmmnt ; Mmt ;Aow*t 2 For. Ejch. T a.A% Taxes

rsss--s s:s1 :S:: tft £Zfh XIS =_ =S==8 :8S Z55Z tSfl :5:5:S: S X: fStSS aS S nS.aS a. =aS:=Sm88 =:::-n sa--

I . INIVESTIENT CSTS

A. ClE ken - 1,404.9 12., 2,164.0 19.6 139.4 1.3 - - 6152.4 33.3 1,160.4 10.5 11l21.2 44.2 4P372.2 6,367.5 261.53. FIIT - - 37.5 12.0 225.4 30.6 20.8 2.3 - - 3M3.1 31.0 25.3 3.5 732.2 2.9 275.3 441.7 14.6C. UTEDULS 1,437.3 43.2 614.3 17.C - - - - - - 1#290.2 37.5 50.3 1.5 39442.6 13.3 2,400.0 M2.2 50.33. E1IIIT 185.7 23.6 15.7 2.0 175., 2:.3 EE.0 11.2 - - 312.5 39.7 9.7 1.2 736.7 3.2 umt.0 0.0 9.7E. YlIOES 94.3 11.9 - - - - 101.E 12.9 - - SC.6 74.2 7.9 1.0 7"9.7 3.2 732.8 - 7.9F. TIEDIICL AISTAIICE 41.3 2.5 - - 10. 0.6 214.8 17.4 - - 1,29.7 75.4 - - 1a632.0 6.5 196M2.O - -C. KM FUS - - 56.6 3.6 233.0 3Z.6 - - - - 315.0 48.1 50.2 .7 64.9 2.6 - 642.1 12.714. _IT UII , KIES * EVMIMTI - - 21.3 3.9 - - 69.6 2S.3 - - 155.0 62.9 - - 246.5 1.0 - 246.5 -1. JCTIVITIES 4. 100.0 - 4.6 0.0 - 4., -J. TamUl1 773.9 24.2 1.037.4 32.4 - - 16.9 3.4 373.0 27.3 402.5 12. - - 3,199.5 12.3 - 3,19.3 -K. 151ull - - 30.1 13.3 63.4 27.4 - - 137- 39.3 2 0 .9 231.7

low1 UDlE DI Tas 2.5.3 11.4 3.269.2 14.4 2,OO7.8 1U.3 776.6 3.9 373.0 3.3 11,020.6 43.3 1,303.3 5.7 22,742.3 91.2 1.471.6 11,14.3 356.6

H. - 5311

A. O EB - - 132.2 20.0 342.6 45.0 - - - - - - 21.1 34.9 60.6 30. 743.6 -3. 1 T M 111 U1 - - - - 614.2 75.3 - - - - - - 231.1 24.7 315.3 3.3 65.4 U4.9 -C. _ 1 T E - - 24.5 22.1 71.5 64.4 3.7 3.3 - - - - 11.3 10.2 111.1 0.4 3.6 n-s -3. ROLM 15ina - - 107.1 23.9 232.2 53.2 51.1 2.2 - - - - m11.3 n2 511.7 2.1 4332 14.5

TOW m1 1 - - .3 12.9 t,310.5 59.6 14.8 0.7 - - - - 1W.3 26.1 ,196.7 3.3 1.13.2 10161.5T1e lal uemmA 2,39. 10.4 3 3,5.0 14.2 4*113.4 16.5 3.4 3. 375.0 3.5 11,420.6 44.2 14393.3 7.6 24,941.2 15.0 1161.9 112,95.7 356.6e as.s as... asas 5 _ am fl s Sa _ae £5su

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C. Procure2Mnt

4.07 Procurement arrangements are summarised in Table 4. It isexpected that 27S of total project costs would be procured throughinternational competitivo bidding (ICB), 18S through local competitivebidding (LCB), 452 through other methods which include 2S for force account.and 10S by other meas. All donor contributions in the project will beparallel financing. with procurement and disbursements through theprocedurer of the rerpective donors. The remainder of this paragraphapplies to the IDA financed part of the project. The civil works contractfor the construction of the district hospital at Msinba (includingaecomodations), estimted at about US$2.6 sillion, and the civil workscontract for the Zomba School of Nursing will be awarded following ICBprocedures. Local firms bidding for these contracts will receive apreference of 7.5S. Other civil works. including 12 rural health centerswith bsming, tbree regional health training centers; and a functionalliteracy regional training center. are too small and scattered to attractfims from outside Kalawi. These contracts will be awarded followingcompetitive bidding advertised locally. LCB procedures have been reviewedby IDA anl found acceptable. None of these contracts is expected to be overUS$70,000. The remaining civil works (upgrading siz existing rural healthceaters and associated housing. 10 shelters and 163 fish ponds) will becarried out by force account of the Ministry of Warks and Supplies. Thetotal of force accounts construction is not ezpected to esceed US$.53million. The local construction industry is well developed and has thecapability to undertake these activities without difficulty.

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MALAWI: SECOND FAMILY HEALTH PROJECT

Table 4: Procurement Table 1/(USS million)

Procurement Method

ICE LCB 2/ Other 3/ MA 4/ Total

I. INVESTMENT COSTSA. Civil works and

design fee 3.77 3.87 4.04 0.0 11.68(3.20) (3.27) (-) (-) (6.47)

B. Furniture, equipment.vehicles. materials 3.05 0.57 2.13 0.0 5.75

(2.33) (0.23) (-) (-) (2.56)

C. Technical Assistance 0.0 0.0 0.34 1.29 1.63H H H _ - (1.29)

D. Monitoring, research.eval. & other materials 0.0 0.0 0.9 0.16 0.25

(-) (-) (-) (0.16) (0.16)

E. Training (0.0) 0.0 2.8 0.40 3.20(-) (-) (-) (0.40) (0.40)

F. Overseas training 0.0 0.0 0.09 0.14 0.23C) C-) (-) (0.14) (0.14)

II. RECURRENT COSTS 0.0 0.0 1.61 0.59 2.20

Total: 6.82 4.44 11.10 2.58 24.94Total IDA: (5.53) (3.50) (-) (1.99) (11.02)Z 27 18 45 10 100

1/ Numbers in parenthesis show the costs to be financed by IDA.2/ Includes items procured under prudent shopping procedures.3/ Other includes items financed in parallel by donor agencies.4/ NA includes activities not subject to procurement.

- 41 -

4.08 Furniture and equipment would be grouped am for am possible intocontracts valued at US$100,000 or more procured through ICB. urniture andequipment contracts valued less than US$100,000 but more than US$20,000would be procured through LCB up to an aggregate amount not to exceed US$1.0aillion. Iteme of furniture or equipsent valued at less than US$20,000would be purchased by prudent shopping with at least three price quotations,provided that the aggregate value of such purchases does not exceedUS$300,000. The vehicles would be procured as a package through ICB.Supplierx of vehicles would be required to &gree to maintain an adequateafter-sales service and an invaitory of spare parts. Contracts formaterials and supplies required for INC activities would be awardedfollowing competitive bidding advertised locally and in accordance withprocedures acceptable to IDA. Prudent shopping vith at least three pricequotations would be used for miscellaneous items of supplies and materialsvalued at less than US$10,000 provided that the aggregate value of suchpurchases does not exceed US$100,000.

4.09 All IDA-financed contracts over US$200,000 to be procured throughICB would be subject to prior IDA review. Other contracts would be subjectto selective post award review.

4.10 ?or all IDA-financed consultants eiployed for this project,selection procedures, qualifications, experience and terms and conditions ofeuployment would be satisfactory to IDA, and in accordance with the'Guidelines for the Use of Consultants by World Bank Borrowers and The WorldBank as an Executing Agencyn (August 1981).

D. Disbursements

4.11 Disbursements from the proposed IDA credit will be on the basisof: (a) 852 of total expenditures on civil works; (b) 1002 of foreignezpenditures for directly imported goods and 902 for locally pr-curedservice equipment, supplies, vehicles and local training; and (c) 1002 ofexpenditures for overseas training and consultants' services. In order toepetdite the flow of funds for disbursements a special account with aninitial deposit of US$0.9 million would be established and maintained in acommercial bank. Withdrawal applications for expenditures for civil works,equipment, supplies and materials under contracts or purchase orders of lessthan US$20,000 would be submitted against statement of expenditure;supporting documentation would be retained in the implemuenting agencies forreview by Bank supervision missions and for annual audits. All otherdisbursments would be fully documented. It is anticipated that the creditwould be fully disbursed by June 30. 1993. An indicative schedule ofdisbursements is shown in Annex 1, Table 14. This schedule is based on thestandard disbursement profile for Malawi.

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E. Accounts and Audit

4.12 Project funds would be maintained in a separate account and wouldbe channelled from the Ministry of Finance to the MOH for Part A and to theBP and D for Part B and would be administered by the respective DeputySecretaries. Project financial records would be maintained by the ChiefAccountant. MOH for Part A and by the Chief Accountant. Office of thePresident and Cabinet for Part B. The Office of the Chief Accountant. MOHwould be strengthened by the addition of an accountant solely for theproject who would receive training by IDA staff in IDA's accounting.auditing and disbursement procedures. The project would be subject tonormal government accounting and auditing procedures, which are consideredsatisfactory to IDA. Assurances were obtained at negotiations that (i)audits of project accounts and SOEs by the Auditor General or independentauditors acceptable to IDA would be carried out. (ii) that all auditedaccounts would be made available to IDA within 6 months of the close of eachGOM fiscal year (para. 7.01 j)

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V. PROJECT IMPLDMENTATION

A. Status of Project Preparation

5.01 The project was prepared by the MOH in collaboration with theMOCS, BP and D, Information Department. and Youth Department. The NationalHealth Plan (1986-1995) and the IDA Population Sector Review provided theframework for project development. In addition, the Malavi Civil ServiceReview Commission reviewed the structure of the MOH and a new organizationalstructure was recommended (para.2.29). Site plans, sketch drawings anddetailed working drawings for the district hospital, rural health centers.urban health centers, family health unit, school of nursing and regionaltraining facilities were reviewed by the appraisal mission, and the requiredmodifications have been submitted to IDA for review. Working drawings.bills of quantity and tender documents for all contracts to be executedthrough ICB have been finalized before negotiations. Confirmation has beenreceived that all required sites have been acquired. Detailed survey workfor the upgrading of rural and urban health centers has been commisxioned toconsultants and ir expected to be completed by April 1987. Equipment listshave been finalized and have been forwarded to IDA for review.Implementation plans for MOB and non-MOH programs have been drawn up. Termsof reference for studies and technical assistance have been finalized.

B. Organization and Management

5.02 The Principal Secretary. MOH would have overall responsibility forisplementation of Part A, while the Deputy Secretary. EP and D would haveoverall responsibility for coordination of Part B of the project. For PartA, a full time project coordinator, accountable to the Chief of Healthervices. MOH, would be appointed. The project coordinator will be assistedby a technical advisor, a procurement officer, an accountant, administrativeassistants and secretaries. For Part B, the head of the Human ResourcesUnit, NP and D vill function as the project coordinator. The Governmentagreed during negotiations in principle that the EP and D would play acoordinating role for multi-sectoral family health activities. Twocoordinating committees for Parts A and B will be established. For Part A.the Principal Secretary, MOH will chair a coordinating committee whosemembers would include the Deputy Secretary, the Chief of Health Services(CHS), the Chief Nursing Officer, the Chief Health Planning Officer, theChief Accountant and the Project Coordinator (para. 7.01 k).Representatives of other MOH units would be co-opted to the committee asnecessary. The coordinating comittee would meet every month to discuss theimplesentation of Part A of the project. For Part B, the Deputy Secretary,BP and D will chair a coordinating committee whose members would include thePrincipal Economist, Principal Secretary MOCS, representative of Departmentof Youth, Deputy Chief Information Officer, DCMO and the head of the HumanResources Unit. The coordineting committee would meet every month todiscuss implementation of Part B of the project. The Principal Secretary,MOCS, would monitor the implementation of activities under Part B of the

- 44 -

project. An overall project coordination committee would be established,not later than October 1, 1987. for both parts of the project under thechairmmn3hip of the Principal Secretary. EP and D and would meet quarterlyto review progress of the project. Members of the committee would includethe Principal Secretaries of the MOH, Ministry of Works and Supplies andMOCS, the Chief Information Officer, the Administrator or representatives ofthe Secretary for Youth and the Malawi Young Pioneers, and the respectiveproject coordinators (para. 7.01 1). The EP and D is being strengthened aspart of the Structural Adjustment Program. In addition, UNFPA proposes tofund the establishment of a population planning capability in the EP and D(US$512,000 over five years). The project is expected to start in mid-1987and be completed by December 31. 1992. the closing date being June 30, 1993.

5.03 The Principal Secretary. MOWS would be responsible for the civilworks program. A clerk of works would be appointed in the MOH's PlannIngUnit, accountable to the Project Coordinator to assist the MOWS inimplementing the civil works program. The production of architecturaldrawings for the project would be managed by the MOWS, which would alsocoordinate the quantity surveying and mechanical, electrical, structural andcivil engineering inputs of design work. Since the MOWS does not havesufficient staff to handle these functions, use would be made ofconsultants. During negotiations assurances were obtained from theGovernment that a clerk of works and a procurement officer, to follow up onall procurement, will be appointed by October 1, 1987 to the Planning Unitof the MOH (para. 7.01 m).

5.04 Procurement of furniture, equipment and supplies, and recruitmentof consultants for both parts of the project would be undertaken by thePlanning Unit, MOH which has the capability to undertake procurementefficiently.

5.05 Responsibility for iriplementation of each component undertakenunder Part A of the project would rest with the applicable section of theMOH, i.e., the Controller (Clinical Services), the Controller (TechnicalSupport Services), the Controller (Family Health Services), and theController (Community Health Services), whose positions would be establishedand filled by October 1, 1987, and who would supervise respectively themanpower development and management component, the support systemscomponent, child spacing and nutrition programs and the primary health careprogram (para. 7.01 d). Responsibility for implementation of each componentundertaken under Part B of the project would be as follows: The PrincipalSecretary, MOCS would be responsible for the functional literacy and women'sprograms; the Administrator, Department of Youth for vouth programs; and theChief Information Officer for IEC programs.

C. Monitoring, Reporting and Evaluation

5.06 Each project coordinator would have responsibility for monitoringthe progress of implementation of their respective part of the project. Theproject coordinator for part A would prepare quarterly progress reports and

- 45 -

would highlight major issues needing resolution for Part A of the project.He would also prepare quarterly progress reports for Part B of the projectunder the coordination of the Deputy Secretary BP and D. These reportswould be approved by the project coordinating comittee (para. 5.02) beforesubmission to IDA and other donors. Regular coordination meetings of thedonor agencies will be held in Lilongwe. As a basis for monitoring, annualimplementation plans will be prepared from FY88 onwards and the mid-termreview based thereon will be carried out not later than December 31. 1988;during negotiations assurances were obtained that such plans will besubmitted to IDA annually four months before the beginning of the Malawianfinancial year (para. 7.01 n).

5.07 A number of process indicators would be utilized to monitorprogress. These would include: for the PEC program, the number and typesof training and refresher activities undertaken annually; for management andsupport systems accomplishment of national and district training goalsannually for the MCH and child spacing programs, the number of womenreceiving services (para. 5.09) and types of training and refresheractivities undertaken annually; for INC activities in the MOR and othergovernment agencies, the production of posters, booklets and manuals.Details of the proposed process indicators by year are given in the Annex 1,Table 15.

5.08 In addition to the process indicators discussed above, severalsurveys and studies are planned. First, a bate-line health status andutilization survey is planned for 1987. Second, a study of the impact ofrevised fee schedules on utilization of services and the potential forhealth insurance is planned during 1987. Third, annual plan assessment andreview workshops are proposed. Fourth, annual impact studies of variousprograms are planned. Fifth, a mid-term evaluation of the PHC program isplanned towards the end of 1988. Sixth, a special evaluation of the BPI isplanned for 1989. Finally, a tuberculosis prevalence survey will beundertaken in 1989. Assurances were obtained from the Government that theresults of a series of surveys would be made available to IDA within threemonths of their completion for review and comments (para. 7.01 o).

5.09 To reach a contraceptive prevalence rate of 10% bv 1991 annualtargets by method have been developed. In making the projections, currentcontraceptive prevalence is assumed to be 2% and current total fertility istaken to be 7.7. If the 1991 contraceptive prevalence rate of 102 inachieved then the total fertility would be in the range of 7.0-7.1. Am aresult, the number of women using contraceptives during the project periodis expected to increase by about 452 to about 55,000. In this scenario ofmoderate fertility decline, population would then increase to 17 million by2015. representing a 702 increase in population in 30 years as compared to a2002 increase if fertility were to remain constant. A paper detailing howthese targets were calculated is available in the project files. Thefollowing table sumarizes the targets of annual number of acceptors per1000 Married Women of Reproductive Age (MWRA) during the project period,

- 46 -

MALAWI: ESTIMATED ANNUAL NUNBn O ACCPTORB (IN THOUSANDS)per 1000 ISRA

1987 1988 1989

Female Sterilization 2.21 3.67 5.21Inj ectabls 1.25 1.43 1.62IUDu 5.09 6.28 7.47Pills 27.50 32.00 35.32Condoms 2.89 4.27 5.89

- 47 -

VI. PROJECT BDEQITS, JUSTITICATION AND RISK

A. Benefits and Justification

6.01 Th. proposed project is designed to continue institution buildingactivities initiated through the first project, to consolidate an epandpriority program such as primary bealth care and child spacing begun underthe first project. and to introduce family health activities through a.lti-sectoral approach. It draws heavily on the recently prepared NationalRcalth Plan and the IDA Population Sector Review. The project is expectedto ensure that ezisting resources are used with sauimum efficiency. Throughthis project the Government vould make the priority investentt needed toameliorate the poor health status of its population.

6.02 Through increased coverage of peripheral health services, theproject is expected to reach iver 1.9 million people. The benefits to thispopulation group would primarily be improvement of bealth status. Increasedcoverage of peripberal health services would also provide access, for thefirst time. to child spacing services in rural areas. At the districtlevel. strengthening the bospital system and provision of surgiealcontraception units would provide a complete rnge of child spacingservices. The institution of in-service training would ensure that thequality of service providers remains of good quality. Activities to improvemnagement and support systems would have both short and medium benefits.In the short term, there would be iaprovemente in the anagement of healthprograms. The development of objectives for various units and jobdescriptions at each level would strengthen managment capability. Emphasison the team approach at the regional and district levels would ensure bettercoordination and implementation of health program. The restructured MOBwould ensure that there would be a more rational use of manpower. Continuedstrengthening of health planning at the national and district levels wouldensure that health prograus are designed to address priority healthproblew. The implementation of new accounting systems at the NOR at thedistrict level and in the hospitals would enable better monitoring ofexpenditures and would improve fee collection. Expansion of thepharmaceutical system up to the district level would furtbhr improve theeffectiveness of the distribution systes.

6.03 The impact of the project on morbidity, mortality and fertilitylevels is likely to be slight during the three years. However, programs inf4aily heulth, disease prevestion and nutrition supported tbrough theproject are designed to have significant impact in tbe modium term.Reduction of the infant mortality rate from 151 to 100/1000 live births and0-4 cumulative mortality from 330 to 210/1000 live births are targets for afive-year period. While this substantial reduction in infant and ehildmortality is not likely to be achieved in the stated period, the specificand targeted approach adopted sbould yield significant progress towardstheir achieveomnt. The time reuuired to meet the targets will depend

- 48 -

importantly on overall socioeconomic progress and ultisectoral efforts toreduce the prevalence of malnutrition. The target contraceptive prevalencerate at the end of five years is about 102 for modern methods only. Thereis no target for traditional methods. Though there is persistently highdemoad for child spaeing services, the achieveenwt of this target independent upon bow quickly those services can be made available throughoutthe country.

6.04 family health activities through the multisectoral approach areepected to benefit about 2.5 Sillion people. Of these, about 600,000people would be reached through the functional literacy program, 300,000through the women' progrms, 100,000 through the youth programs. and 1.5million through INC activities. These activities are expected to increaseawareness of family health problems in the sbort term and in the mdium termresult in demand for family health services.

6.05 In view of the difficult financial situation existing in Malawi. acentral concern of the design of the proposed project was to ensure itsaffordability to the Gavernment. Of particular concern ws" theaffordability of the project's recurrent costs, which is expected to be K1.1million. The incremental recurrent custs are rema*ably low for a projectof this sze. This is because tbe Governent's strategy has been to limitexpansion of services with significant recurrent cost implications and toexpand only those high priority programs with low recurrent costimplications.

6.06 Coot reduction is expected to be realised from improved accountingprocedures, bill collection. monitoring and control of expenditures and fromchanges in bospital treatment regimens. Aggregate figures for the period1976/77 to 1984/85 show that 872 of the MOH's recurrent budget goes tocurative institutions (l12 for administration and 2S preventive care). Thetwo central bospitals alone account for about 332 of total MOH recurrentexpenditure. Studies of the operations of these hospitals finaceed throughthe IDA-supported health project reveal that about 442 of their non-salaryexpenditures can be saved. This could be done without affecting theiroutput in the following aroeas food, overhead costs, vehicle expendituresand hospital supplies. The following exmple from the Queen KlisabethHospital. Blantyre, illustrates the potential savings in Kwacha from oneitem - overhead costs - through improved management.

Overhead Current Cost Pro eted Cost(1985) (1990)

Water 342,705.24 68,541.05Coal 128,851.52 0Blectricity 105,928.45 105,928.45Telepbone 92,968.00 37,187.20Other overheads 10,330.65 20,330.65Total Annual Overhead 680,783.46 221,986.95

- 49 -

6.07 AssUming that the cost reduction measures are graduallyintroduced, the project is epected to result in savings of about X8.4million by the end of the implementation period. In addition, the WE hasinstituted a sebmse for cost recovery. At the en of the project. X4.4sillion are ezpectnd to be recovered from fees. Cost recovery would rise toX5.3 sillion annually by 1990. Vith implemntation of these cost reductionand cost reeovery measures the NOR would be able to *eet the incrementalrecurrent budget requirerants for the project.

6.08 Most of the activities proposed under the project have been pilottested in the country through the IDA-assitted first project and suitablymodified to permit the expansion proposed in the second project. Inaddition, the phased approach to implementation of the Government's fve-year program will enable further modifications as the activities arereplicated nationally.

B. Risks

6.09 The project has three main risks. The first concerns therestructuring of the MOH. The MOH has had intrinsic weaknesses in itsorganizational structure and hs had few qualified and experienced seniorstaff. Factors beyond the NOH'c control make it difficult to undertake theproposed reorganization. An inter-ministerial task force headed by theSecretary 5 Office of the President and Cabinet has reviewed therecoweadations of the Malawi Civil Service Review Commission. The NOR hasbegun to make organizational changes and has recently added senior staff toits managment. Additional managemaet studies are being undartsken andprogress in dveloping a noew structure for the NOR is satisfactory.

6.10 The second risk concerns the civil works element of the project.Implementation of civil works in the IDA-assisted health project has beenslow. In the past. the MMO has been unable to adequately brief ad monitorthe NOWS. urthermore, the 08S has been critically understaffed for abouttwo years. This has resulted in significant delays in completing civilworks in the first TDA assisted bealtb project. The following steps havebeen taken to minimise the risks: (a) the MOWS has hired expatriatearchitects to reduce its staffing problem; (b) sucb more use is currentlymade of consultaats by MOBS than in the past3 and (e) project preparation isat an advanced state, with tender documents for all ICB contracts ready.Finally, the project provides for a clerk of works and a procuremnt officerto be attached to the MOW (para 5.03) to coordinate work with NOMS. Withthese steps it is likely that the civil works elemnt will be carried out asplanned.

6.11 The third risk concrnes the introduction of faily healthactivities through a multisectoral approach. The UP and D has recently been

- 50 -

reor5anised as port of the Itretrel djustmt rn.rou m_ Lg epected toplay a coordiutimg role for mltieetoral actLvLties. Oly LfreorganLsation prows to be m_eewftu. am the N _ D play itg roleeffectively. Thro%k aitie_1 statffigs higher leel tnimiag aldteebchnal "dsstace, th. mle wll be develoe grdelly. Thek hanot had ay associatLas with the 1=. the Depe-ttot of YTethe or theInformatLon Depart_et- at, hltgb thes offices he a gOd track record ofimplementing other projects. The project propses to a fEmily health intoaziting progrm omly at this stage. wed em the inperieam with projectimplemtatioL major expassion of fally halth pregrens esld be co ideredat the nezt phae. The steps outlimd aboe re, inpeted to mae theproject manageable.

- 51 -

VII. ASSURANCES AND RECOHUEKNDATIONS

7.01 During negotiations tho following assurances have been obtainedfrom the Governaentt

(a) that it vill submit to IDA for its review and coments, a revisedorganization chart for MOH by September 1. 1987. and formallyadopt such revised organizational chart by October 1. 1987 (para.2.22);

(b) that should the Borrower propose to make any investment in thehealth sector which is not included in the first five years of theBorrower's National Health Plan (1986-1995). such investment shallbe made by mutual agreoment between the Borrower and theAssociation (para. 2.51);

(c) that the health centers, once completed, will be adequatelystaffed by at least one medical assistant and two enrolled nurses(para. 3.09);

5d) that the positions of three regional health officers, threeregional nursing officers and of four Controllers each forClinical Services, Technical Support Services. Family HealthServices, and Community Health Services will be created and filledby October 1. 1987 (paras. 3.13 and 5.05);

(e) that it will carry out the program agreed with IDA for costreduction at MOH and the various hospitals (para. 3.14);

(f) that the positions of one expenditure control accountant at MOH.three regional accountants and one accountant at each of the threemain hospitals will be filled by October 1. 1987; that theposition of 21 assistant accountants for each of the districthospitals will be filled by August 31, 1988 (para. 3.16);

Cs) that a training officer will be appointed to coordinate in-service training activities by September 1. 1987; and that annualin-service training plans for the GOM fiscal year beginning April1988 will be subsitted to IDA for review and co_ment by December31. 1987. and annually thereafter (para. 3.17);

(h) that six clinical officers and 16 enrolled nurses will beappointed to the urban clinics once completed (par&. 3.22);

;1) that the MOH establish by September 1. 1987. a healthinformation. education and communication review

- 52 -

committee chaired by the Chief of Health Services, withmembers from the Ministries of Health and ComunityServices and the Secretary for Youth and Malawi YoungPioneers to approve IEC messages prepared by non-MOHagencies (pars. 3.28);

(j) that audit of project accounts and SOE's by the Auditor General orindependent auditors acceptable to IDA will be made available toIDA within 6 months of the close of each Government of Malawifiscal year (para. 4.12);

(k) that it shall establish a Coordinating Committee within MOH, withthe Principal Secretary of MOH as Chairman, including the ProjectCoordinator for Part A and representatives of the various units ofMOH involved in project activities, for the purpose ofcoordinating the activities under Part A of the project (para.5.02);

(1) that it shall establish a Project Coordination Comittee not laterthan October 1. 1987. consisting of the Principal Secretary of BPand D as chairman; the Principal Secretaries of MOB. MOWS andMOCS; the Chief Information Officer; the Secrtary for Youth andMalavi Young Pioneers or his representative, and the respectiveProject Coordinators for Parts A and B of the project's activities(para. 5.02);

(m) that a clerk of works and a procurement officer will be appointedto the Planning Unit of the MOH by October 1. 1987 (para. 5.03);

(n) that as a basis for monitoring. starting from FY88. annualimplerentation plans will be submitted four months before thebeginning of the Malavian financial year; and a mid-term reviewcarried out not later than December 31. 1988 (para. 5.06);

(o) that the results of a series of surveys would be made available toIDA within three months of their completion for review andcomments (pars 5.08); and

7.02 Subject to the above assurances and conditions being met, it isrecommended that the proposed project constitute a suitable basis for an IDACredit of US$11.0 million equivalent to the Government of Malawi.

- 53 -

Na)lia ISKc Feuily Health ProijtThe Teo Lbeinq Comm e kith in Chilirm 0-4 tows, 93

f r b023 Ruwtw ospital Deths

Totalftw 2 kccuiuatia

At,eu. Deaths Deaths Prcatw

l, %"n 97! li.2 14.22. PunUsa 734 13.0 29.23. tritimal delficiency 73 11.2 4.44. kI wrt a11 10.1 50. 5S. Amid 549 9.1 5I9.4. iirrhei disas 504 3.4 id.07. T,t 25 4.2 7L2. hiuase ii the NV's svstn 94 1.4 MIl

9. Acimuts MW iljUin 39 1.5 75.310. Terclois 2S 0.5 75.1

A 1, ble 2

klami McOW hSily WIlth ProJeCtThe To Nut PteIm_t CAM .4 htpatint Visits for

Ag 3-4 .i 9M fro 4. uallim vniits

Porcelta40 Acuml atlas3jnuas of TotaL Porcontage

l. kelria 35.6 5.42. nWirstor imfectils 39.1 35.4L htw whdi MM 3.7 44.14. laflma tir m of t eye 7.9 2.IL Ms a _u L& 77.6b. id.al ad It y"toU 5.2 a.l7. Tram wa itt 3.1 15.93. ubil 2.3 3.29. ktritim 4@*cimci disea 2.2 ".410. * VW" m stbu helthtairs l.b 9.0

- 54 -

Am 1, Table 3

Ii Si nai Faa ily etU ProjetNN lmultal Ii Capacity ad ktccpatilu

(by Lwl of kcpcy) .

Avwage No.hi 4Imtiuts Avw

lpitai C4apcity w Dy

llija 41 104.5 a4.SMtcftts 23 47. 241.1

tooka, $~~~24 170.9 174.2Ulosw 37 on. IJU25.

Chikuaue 114 149.0 14.2Ns16a,a 137 1,0.0 131.7u*a 105 144. 137.7

KUg 142 201.0 123.5Ncljtt 74 93.4 12tottm I" M.1 11.2NWacMaa 54 5.4 10.2Thyulo 133 144.1 1 lO4Kutupro onu a 100 1l1.0 101.0INWchi 204 20.1 ". INinab 133 134.3 9J,Slaityre N4 347.1 95.IShtakuta 131 124.1 94.7Nkhataiev 97 91.4 94.2bsi 144 13.0 92.s1mi. 154 131.9 53.3Ciraituis 115 93.4 61.2hu 123 101.9 so.tChitip 73 t2.2 71.5

15 0 ".0 53.3

- S5 -

Annex 1, Tabl.e 4

Rulait CSeeig PFa sl tJi ProjetON Stafia t stiW, Joe 914

ITWP WPFMAlt OFCATR? EUTILIUsT In FMS ISTuES

No4ical. Office 134 14 42Dital Officr 11 I 73Clinical Off jw 1m 17 97hical Ausistut 517 351 isR"esturd rus 497 347 14Emnulled Iu'siN 93 919 101Pwusast 13 9 49Phe'uy Tuuicil b I' 17pharmy imsstit 32 123

bmratme Te iasin 29 23 6Lamwaton i itat 3 a 6Radzognahr 17 9 53I4ayAuistt 9 I Dital T cta 1 7 64Deotal uAi at 12 9 7nPryst/OT 12 6 34

ealth las tra 101 73 69Wlth usi tat 231 to nother U2 191

Total 42 23

- 56 -

AMxmc 1, Table 5

Malawi: Second Faily Health Project6rguth of Wealth Service Staff (1977-1933)

for All Sectort-.0, PM, Local eovt

z Change

¼uee: o, Sta 1971 ('13 * Year?:

;. C:;n;;a ot':c 79 1r2 very larle; * exca1 assstant 525 iU2 *20Z

q"uieif nursetetdwit 397 519' rotlled nursommit:1 1040 1'55os0

:.f^tl1 P.5^,iI5;3tAfit 4 3er Iaq3. pIarqscl o'

. .aleratoty t:c~n:an;:I Ii. tratary teclnncin 1; 4 *20Z; -ab t�o rv assistuat ob 91

.:. oioqraeOIO * 20 verY lwqe;:. tIv aslistaft ' li VerY large:. 4es1tn .npecto 74 ';'. HcaI:n ecutator;. n;;. euaitl aZsistint loS :li iv,' 5rutacv assistant i : erv larqe

:. ts 1352

'.zt otal in tOH 55

.. ~..e...fll..in._ee.inee............O.___

t aen i om StatIstg 19 nt l6: R itff Acrd am at Uarv al .;;orls iiic. iWO Cotrv Prograsing Documt !97, inad drld 3ink Aegort, 1951

57 -

Aui 1, Table 6

ele int Secod Full 1talth ProjKtAverwo Attiitiou latn frt the Os 19S1119 3

Total Total %a[ml" Laws Attrition

CATE 1914 1a14 lte

Clinical Offices rs1 12 3.41lmpistwi N Um 613 31 3.L6brolled Nr/" tdvvn 22m1 49 2.t2Nedical Asistats 9 47 4.91II uh kmstats 436 17 3.91Laratory sistats 144 3 2.LSParmy istats 132 5 36.1

A 1, Tab 7

MILANIt SCON, FAILY kHE PlOJECTR1O RECUIENT EPOSITIS 1M11/82-193/4 BY S OUFCE O FINANCE

'14Totl LipeediturwMu- Finaced by

Truiwy Radical Treasury Mo-TreawyYear Aloclatio Fe" Perm.el Drus Sources Sources

19R546 37 1046 2400 iGC 941 261914/l 20031 U4 2400 2000 516 1t1931S84 2059 s3 2U00 2100 523S 251912/63 17422 537 2300 2100 497 231931.62 I1m 3M3 2300 3100 5793 31

NOTEs:1. ata on fs and eleoditure fro the alaui bverRet Estimutc o4 Espoditure.2. Foreign oMeical prsoeel eployo th owb tKchiCAl us11t1ACI though

pots to their iqn. The RN pays th local rate ad thb Suw tng aw iIciSpays the differoce betvme the kom rate ad the local rate.

3. Fedral le lic e# rmy aNd Stat hrit.i prwide r wport.

Source, Estimate by lBak Rtssiom, 195.

- 58 -

Am= 1, Table 8

WalsI kScd FaIly IIa1th Project0 IH fCm fre Fm 1975/74-19iO )

Ip ptatiua it Aid Aspretatiun is Aid it CmtaUtis Carrot Price 2/ Prices (171/79100) J

ore"lsopditere Cwrutia Cn"Ut M I.4 rees cuetatPrien ktul Euputtwe Pricn Per Ciait

Yw WONI (KIWI (1) W(006) (K)

19316 30 lw? 4.3 43 0.10(1st.)19,3/u 24069" 3.4 472 0.07(hvl19; /P1 2100 W3 3.2 35 0.011932/U IJin 57 3.3 3 0.o01"91/2 1ism 1.w 11 S.5 744 0.12;"ont1 14* 49 L. m 0.0o1iti/ 1206 393 3.2 33 0.07173/79 t03 314 3.7 54 0.0797/73 7761 349 4.5 42 0.011974/7? 74 2 4.2 334197"5/ a" 27 4.3 370

NMI5Il/ ,0 00 of this m on Sritiu Cuuity aid.V Aoopiatims is aid ijclue fe aid d rtutal rectits too

e`010r ssts. Th latte iS is te eibtrON eu 13 14 the totalwpwir tius is aid.

slrce: kuW i Halst hwrumt wrui estiated o4 hohstitmrs.

- 59 -

Amux 1, Table 9

MALAWI: SECOND FAMILY REALTH PROJECT

MM0 ACTUAL KICUUENT EDKNDITUZ BY ACTIVITY AREA(3~76,'77 -1984/15)

AdNa- Preventive Curativetcratelon and Control L tl-

WIAR Tr?a^t± tutions TOTAL

L' 000 2 R'OO 00 2 lo t' 000O X '00

1965/86 30069 13 19360 6 Islas SI 23,57 100(esc.)1964/85 2,769 14 1,526 5 22,963 8 28,031 100( rovisd

"t.)1983/84 2,645 12 1,221 o .7,734 82 21,600 1001962/63 2,108 12 1,121 6 14,193 81 17,422 1001981/82 2,377 13 948 5 15,336 82 18,663 1001960/81 1,693 11 910 6 1.2 .377 82 14,980 1001979/80 1,440 12 802 7 9,841 81 12,083. 1001978/79 1,048 10 634 6 8,645 84 10,326 1001977/78 956 12 466 6 6,338 82 7,761 i001976/77 - 833 12 615 9 5,636 79 7,761 100

Total:t976/77-1965/86 19,711 12 9,603 6 131,693 ,9 161,007 100

Source: Used on Malavi Governmnt approved stiato of esp4diture.

- 60 -

Aiim 1, rbl. 10

75/76 - 5/86

agjl & g - Qr-ut w ( aw P ( 1 79)Ir ,P.-=G,m) pd ) l

fra±qg & io1 ~ Su sca & 'I brv±cu lbal*Ys _ (A) (b) (c)).(b) (a) (b) (&a)*b)

1981/86 687 43 6,56 8,066 290 309369 5,953 9,S 15,47819648S5 794 758 5,797 7,349 £0,62 28,031 5,837 10,777 16,6141985/J 539 643 5,619 6,801 14,79 21,599 5,29 8,351 13,8801962/83 537 49221 _5,385 12,037 17,422 4,573 7,566 12,1411911/82 435 437 3 55 14,297 18,723 4,166 9,846 14,0141960/81 359 318 2,857 3,534 11,446 14,960 3,506 8,636 12,1441979/W0 358 320 2,46 1,140 8,943 12,013 3,140 8,733 11,6731978/79 284 176 2,3154 2 ,914 7,412 10,326 2,914 7,412 10,3261977/78 2, a UR 1,735 2,132 5,69 7,761 2,578 6,807 9,387,976/77 165 172 1,95 1,832 5 251 7,0C3 2,356 6,841 9,2271975/76 163 15 1,3.j 1,711 4,66 6,379 2,237 6,249 8,486

.%to. 7ha Pct !=bds u fro 1975/06 to 197&'79 is a 8 I zl-ta . FTo 197&79 to 195/86 onseun L.damwu em Ab.lIa, -- for iinbm d alaaw wd tku actaw for pco cSo ia: I

sas: Bd= ANM%e Ul Of 94:t cm7* m

- 61 -

.Am I, .abb.e

MAL.AWI: SECOND FAMILY HEALTH PROJECT

197/7 - ._86_

MML A1F AL 1 pOL Aal A h: l-_-- Smith +1- ±wu f±tuwU

Gav~~~~Q cvovm DCr M)caL 2 of ocaJ fto. t A. in C=a a osMRw Juw GC a=m 0 %2of Pki Pri.w per- 1960/81-100 capita

i hS~~~~~~~~~~~~~~~~~~~~~~~jl 1980/81-100i ( r azoV= (I'' x ( r 000) (w 0 c0 ( 2) ( ti ooo ( s) (r COD0) ( [' a )

1985/86 156,' 1.2.2 6,263 7,515 48 _ .

191w/85 134,L55 11,1', 7,731 8,87 6.6 - _1983/84 I,O6 733 6,2w 6,935 4.3 6,519 6S 3,679 0.56191/83 138,716 210 2,386 2,59 L9 1,378 47S 8" 0.1419U8L/ 138,724 34 2,65 2,68 L9 1, 55 Ez I,m 0.1219081 165,39 66 3,316 3,384 2.0 4,246 2U.52 3,205 0.531979/80 147,830 D 44 2,643 3,067 2.1 2,726 1L L 2,6a 0.451978/79 13,479 43 1,171 1394 1.2 1,007 36.I 1,0X7 0.181977/78 96,224 29 1,070 1,199 1.2 87 27.= 1,0561976/77 60,189 220 2,196 2,416 4.0 1,674 30.7: 2,180

co: Mu .a - _p_sds-c for ^ W

Sw: B A b f.t t C*a c.qt wm

-62-

(Lus ce'uwn '6662 'NU

961 1913 :9 fou 396 14 iw Foul..-

ie sm

POW *IY2.6Ca 219.7 3.3l 171 941.3 13,5 15.3 1 03_. 128.12,033 W "KI su3 2,6Th? 4.733 31-1.318,196.4 I41.6 2#034 3,996. b4b.

3. IIUSU U 121 ftV. 1133.319,.4966 W4P66.2 U.E1.4 1.644.11. 0413.4£209.7

m. mess~ ~ ~ ~ ~~~~~~~~~~~-ooto .mooSN

a. inmmnm 5,099.4 ~~~~~~~~~t CU _ #eta i..e oa.0 431 m.9 us.

L.41 181 694.4 10.6 U., W.l 416.5 4.0 4.3 0

it~~~~~ tp- 01. tl am7 Mt M-9 rlo #

It U n ~ 2 Y3.03 3.3 16.9 1.

6&4 M W 149304 1.34.1 Not9 W.S4 1411 4 9.3 21.2463C. m e m mlu

W. 313 W Uf.m PM * S as 3 13.64 166.9 U.I 8. 4 74 10.4 4.a 9 599,11.t6 9 _1.4 3.51 10. 31. 6S4 1M.e hm M4t

t_l_ 8 ft2. IV- mls .W am 7.9 7.3 3dI ,ows46 0.3 aS 0.3 1AM 3w f8 51. 11.3 3Ml 364 13.9 7.4 11.2 14.4L.31 M AN S GfP 1W.* M4 114 16 Noy 413.4 66. 914.16UUUina UU Imm WI 98 .8 15.8 1 8e 0.1 3.9 W.3 I914

**-I" f_ 0 1 IG11.4.0. @4 'Mt. ?1 NW 2M .4 W.4

t. _t s r43

1. ow n MT80.1 1.143 46.7 Ott WA67 43u W3. 2.3 10493.02. 08809ran 3.318.3 3.073. W5J 7.W. 1.IL4 5o.1. 46.2 4471.41. Um_ m 3*W4 9. W3. 6_ 104 14.7 292.9 662.44. 0 m~ E UZ*VIU 2306.3l .474.0 I,18 4PO3.4 lP.J 8.4 721A 2,140.2L mm 16 s1.9 W. a.: lt?.U, mae .IV us. m..

I. am 34 7.4 t .l as 29. 4. 4.3 3.22. i t147.9 15.3 14.4 3.1 44 84 M 2 2I.4L. lOiUs 141. w. ft? 36.2 . 314 4.3 1. .2

4. mm 31t16 0., 2.w.1 2061.1 6*x.. l.26.0 Is.13. i.*M

~~.ig N30WIni. OPS3 ,6.7 21.31. loill.# 412.18 1.109,4218.2 3.7?4.3

1_B . mm - " 11 .V 94.2 2.319 3., 1.6 142.2 1,440.,

OLI ^1 _M lo op1_e W

to 31210 L1 I ML lo2.22) 7123 1.18.2 3,2664 43.1 117.4 712.3 I,,49,2. vm M9.3 M&# 18.9 75.4 I48 114.4 .81. I.53. 1E18 mi M$4 3112 MA 794 1.4 464 3.0 43.04. PON0 3UEU W Is MI. 2.2990 364 3.184 19.7 1#271.2 iwI 1.1231-L. PON 4 R1 396 344.3 VIL 11.3 9_.? 26.4 1d9.6 146. 112.0

_ . n ~5 0 2*.41. 3,. X.13 .44 .W*w. 1 1.0.02,991 ,18^.2 *1..3

?sgaL zoomsi PLM C"o 23.41.! -M 1.3430.34 71.36. 13.W.0 S.40.2 140494.6 43.086.1

t. ~ ~ ~ ~ ~ m

-Am 1, Tablo 13-63 - Pa gI of 3

b. of swim

iw iws IM mu.-- mX 1 "

PM -WAU cam

tliao wakoce r Sk. Diatr. Offlt. 3 3 3 9S_us, = wot 3 3 3 9bdt _~usm,wtm adC 9 13 X

n ad % ,,N S ia 3 3 3 9*etrd1suit tcuim 3 3 3 9

_ftg~wrcniq i"Mops, dit.i 9 12 s 36's,mu t_ 3 3 3 9

- h pu ubap., vi1V ba _h am 3 3 3 9'_-i~m tzsl.im, Yi1uS b1*b e. 9 12 1 3Am-IgmiW 48cdiact visits 9 12 153D1 iat *Xat 9 12 1 5

m r, m AND mXm"

iq*_ of I S7Itmli.1 tem 1 1 1 3Di.e1at taiai 3 3 3 9f=r tal 4m 1 1 1 3

a%g Pritpam ad aflym4m1 s. apsusy 1 0 0 1$k o O a1s/wfly oft i 1 0 0 1Jm_ ew &m Iu aw,(030 VW go.) 2 2 2 6

_. fur an pSl (130p pw) 3 3 3 9

?8mZ iLn~

F ad auft11 bulmh tf 1 1 0 2

wqi teraw, mFy diem. 1 1 1 3

c 0aft CuomoIs sfm 1 1 1 3TO - nc"is MhellowOflwad Aas1 ma 1 1 1 3

ftm Gmm" na tlw 1 1 l 3Tz C c1ia of.,

G Ai.O1 D1 1 1 1 3

d1sui.t a -.,icre PI a s36

-64 -AMx 1, Table 13Page 2 of 3

lb. of S m

9w7 196 1999 Total

tram for MCU 13 15 39im f frm tn ian 11 13 15 39

ftim for vill bmlth com in X 3 3 3 91n wwCes fo Tr Dti= 2 2 2 6

T=hs* iqwmsefor Me 12 14 14 40lWsb trainft GzAI for M 0 0 14 14

Trait* mag forM in uj uit 6 6 6 18Tra4= gmm fw womn PFP

in uwrid 3 3 3 9

h=Lml -casemWVfrW 1 1 1 3

tcmafwr 6 6 6 1iTWOiniqcuufor Wll 12 12 U 36TMiW =mm f_ lad 1m, 24 24 24 72Trim C cau fw Ptl

Ltiny ia .ns 6 6 6 18Tanq- afor ~tl 1 Ltwu

mQInw ff3 3 3 3 9

TrAW wsu fo -SOCN 1 1 1 3.ahft Cownfw_ m 70" 1 0 0 1

al t11y --6 - emm fw M yon vomv0 1 1 2Trin COIWM fur SI A &21 12 12 12 36

- 65 -Annex l, Table 1'Page 3 of 3

MOAK: vaK x waMU HM mI5. OVS 'PADW

No. of hub.

1967 1966 1969 Total

FUtblsmt of )Iw Fliw ComityOawmuulnh (1Qyr) 1 0 0 1

lrws of __e Spt_hel1m.b (I(lh) 3 3 3 9

UmItb Pluini%ulth ?laww, log come (I y) 1 0 1 2W1th Pauiz, bort wne" (3 inhis) 0 1 0 1

bipi 7iamiF (6 .1) 2 0 0 2

DM ptnt ad SuplyDi" iati (3 me, 2 pa ) 2 0 0 2Do* Aaisiai(6 *u) 1 0 0 1Qjelity Col (6 moh, 2 pm) 0 2 0 2Dnw On.acwe (3 mbs, 2 p ) 2 0 0 2

.'b1 -ov o tuiam Q nod(1 , 10 I) 10 0 0 10

bdm,ca cic md Ccmtato0_w tmuIi (3 t, 3 p me) 3 0 0 3

- 66 -

A 1. Table 14

MU AIa 1300 hhALT! I0WJM

IDA fiscal Tear Diabtaruaet Actmulatd Accumulativeand Quarter ducrta Quarter Disburement Disburseamt*ndinx (98E000) EXE000 , S

FT1988:Sept. 30. 1987 0 0 0Doe. 31. 1987 0 0 0March 31. 1988 330 330 3June 30. 1988 330 660 6

7Y1989:Sept. 30, 1986 330 no 9Dec. 31. 1968 660 1650 15March 31. 1989 660 2310 21June 30. 1989 600 2970 27

nlsso .t- -Sept. 30, 1989 770 3740 34Dec. 31, 1989 770 4510 41March 31, 1990 770 5260 48June 30. 1990 770 6050 55

7T1991:Sept. 30, 1990 7 U 6765 62Dec. 31. 1990 725 7460 68March 31. 1991 605 6065 73June 30. 1991 605 am0 79

7Y1992zSept. 30, 1991 495 9285 84Dec. 31. 191 495 9O0 asMarch 31. 1992 365 1O006 92June 30. 1992 365 10450 95

111993:Sept. 30, 1992 320 10670 97Dec. 31, 1992 220 10690 9March 31, 1993 65 10955 99June 30. 193 65 11020 100

I/ hpectod project co.let4.a June 30. 19922/ xpected closing tate: June 30. 1993

- 67 -

Annex 1, Table 15

ISwn: sCI FBX3L3t

197 1906 1999

1u of d distr ics tdise HE 2 2 2R.u of at cmm .iutabui 7 9 9

b t7s of tuian - MMe:d go 1 h, . Dbtr. Officu 3 3 3

_ isa4m 3 3 3m a t adC 9 12 15

Aree-lwml nt *Xvisits 9 12 15District visits 9 12 15

ti3m, wuisi for di ict-oo~ 15 1D 15~i mi ft i 13 15 15* ~for metwooa 1in15C1

, ^oatc Jw Vilim 1ei6 in CB 3 3 3

Ofd in lie. t 6 * of Spwit di c _ Sr WE (3 de),CI (3 dam) ad 50 65 80

P _WIMqS of chl±o 9-12 ib of a" vith_1e. baiutim 50 60 70

Subw of eopn of f ol.s W21u tim =0 3670 5210M f of incqcm at iajw.1 120 140 16216b of TM uns 50M 62D 7470Subw of pill u 27500 3000 3532D

xiw of c us 290 4O20 590

- 68 -

Annez 2

Documents Available in Prolect file

1. World Bank. Population Sector, Review, 19862. Government of Malawi. FJ_ily health Project Proposal3. Government of Malawi. National Health Plan (1986-1995)4. Planning Unit. Population and Realth in Malawi, 1984.5. Planning Unit. Manpowers Current Situation, future NHeds, Issues of

Managemnt. 1984.6. Planning Unit. The Use and function of Managsemnt Information in the

Delivery of Health Care Services. 1984.7. Planning Unit. The Potential for Income GCneration and Cost Savings in

the Ministry of Health. 1984.8. Planning Unit. Ministry of Health: The Bulget Foroulation Process.

1984.9. Planning Unit. Strengthening Primary Health Care. Principles.

Policies and Strategics. 1984.10. Planning Unit. Health Sector Analysis and Imarging Program_ing

Strategies in the Health Sector. 1964.11. Planning Unit. Pharmacoutical Logistics. 1984.12. Jacobson. S. Appraisal of Civil Vots Component of Proposed Family

Health Project. 1986.13. Ayalew, S. Iconoamic Analysis of Proposed amily Health Project. 1986.14. Hoban, P.C. Appraisal of INC Component of Proposed FImily Health

Project, 1986.15. Detailed Cost Tables for Proposed Jasily Health Project, 1986.16. Bulatao. IA. Acceptor Targets for Malawi. 1986.17. Details of Training Activities to be carried out under Faaily Health

Project. 1986.

- 69 -

Detile Cit Tables (SuasarX Ac-clunts)

1. Project Costs by Expenditure Category and by Year Including

Foreign Exchange Aeount and Percentage (K)

2. Project Costs by Expenditure Category and by Base Costs and

Contingencios (USS)

3. Project Costs by Expenditure Category and by Year. Totals Include

Contingencies (K and US$)

4. Project Costs by Exponditure Category and by Bass Costs and

Contingencies (K)

Project Costs by Functional Component and by Year (K)

6. Project Costs by Functional Coeponent. Totals Include

Contingoncies (K and US$)

7. Project Costs by Expenditure Category and Functional Component (K)

70 - Annex 3.

K"*LAN Table 1uECO0N FMILY HEA.TN PMOJECT

Surw Aowts bw Year(Local Crrmncm '000)

Base Costs Forain Exchang

19t7 198 19 1990 1991 Total Z Amsomtuwaaaaa uuuaawu asamaauu ua:acam mama::. :zaazX=am mss: amuasm:

1. INVESTIENT COSTS

A. CIVIL ORKS S.230.4 7.521.2 2.996.7 392.6 301.6 199442.6 39.7 7p713.0B. FUMNITUkR 3M4.9 542.8 361.6 36.0 - 1,287.3 37.7 485.0C. ATERIALb 780.7 881.2 1,403.7 1.442.9 1.432.2 S940.7 69.7 4P141,6D. EQUIPENT 7.3 383.3 392.4 26.0 11.2 1.386.3 91.8 1,369.3E. UENICLES 1I213,9 149.6 14.9 14.9 14.9 1.406.2 99.0 1,394.3F. TECNNICAL ASSISTANCE 2o240#3 466.1 195.3 138.7 138.7 3,179.1 100.0 3M9.116. DESIGN FEES 1,287.0 - -- - 1287,0 0.0 0.0H. MONITORING * RESEARCH * EVMLUATION 250.8 45.9 66.4 45,9 66,4 475.4 0.0 0.01. ACTIVITIES 9.1 - - - - 9.1 0.0 0.0J. TRAININ6 1.65d.7 19527.7 1,554.5 700.9 700.9 64142.8 0.0 0.0K. OvumSEAS TRAINING 344.0 87.4 21.9 - - 453.3 100.0 453.3

Total IJESTNENIT COSTS 16.935,2 11.605#1 7,007.5 2W798.1 24666.0 41.011.8 45.7 18.735#6

I1. RECUMRENT coSTS

A. SALARIES 191.8 313.7 313,7 113.7 313,7 1P446,7 0.0 0.0D. UENICLE OPERATION ANI NAINTENANCE 280.2 310.9 310.8 310.8 310.8 1.523,2 79.8 1.215,2C. EDUIPIENT M^INTEICE 4,1 26.2 53.3 59.0 57.1 199.7 79.8 159.3D. IJILDINS MAINTMEII - 93.3 251.1 281.8 291.9 918.2 79.8 732.5

Total REDoWT COSTS 476.0 744.0 928.9 965.3 973.5 4.087M 7 51.5 2M106.9Total A INElIM COSTS 17,411.2 12.349.1 7.936.4 3763.4 3t639.4 45099.5 46.2 20484246

Physical Contingencies 19120.3 959.9 538.3 214.4 199.6 3P032.6 52.1 1,579.0Price Continencies 1W204.3 2.063.5 14972.0 1.219.7 1,478.2 7P937.7 46.6 3.695.7

Total PROJECT COSTS 199735.8 15,372,5 10,446.7 5,197.6 5,317.2 56.069,9 46.6 26W117.3a33333333 29 mam anua mauu wall utz C---- Zaamasu: 33amzaaaaaaus12X

Taxes 264.7 255.7 177.8 49.4 51.3 798.9 0.0 0.0Forein Exchanm 9.6926 6.545.7 4.558.1 2631.6 2.689.3 264117.3 0.0 0.0

Fgbruar 51997 17:56

Annex 3Table 2

If01 EMIL! WANi NIET1111 11IF111 1111 iCI

tmcal Ct, ----igs Price Ctam t_

Lw-al L NI ----- Pric eoo.

Ltocl lEiI. %tin a For. (EnI. itnh I For. htw. MEs I Local (tiw. Mios I on facol

For. [nc. T_uo) barn ToLal E(ig. las) Tons total End. Tows) Taxes Total For. E h. Taws) Toms Ido CWA

1. D101M cm

A. CL 3,11.5 5,34.4 2A.4 9,721.3 N6. 5U.4 23.0 972.1 13.0 106.7 5.1 327.1 *M2.2 6.37.5 261. IllQI.2 1901.9

D. F ll 242.5 3.4 12.0 643.7 24.3 U.S 1.3 64.4 9.1 14.5 6.5 24.1 275.8 441.7 14.4 7U.2 66.6

C. Iw_1 2.070.8 16.3 43.2 2'9.3 237.1 I$.6 4.3 297. 122.1 503. 2.7 17S.2 240.. 92.2 50.3 3442.6 313.0

L. _ 666.7 - O.5 693.1 6U.5 - 0.e 69.3 23.9 - 0.3 24.2 m.o - 9.7 16.7 71.5

t. UO 697.1 - 6.9 704.1 9.7? -0.0 0.7 70.4 1.0 0.0 0.2 1.2 7M2. - 7.9 7".7 71.9

F. in IS 1,. - - lP.M - - - - 42.5 - - .5s l62.0 - - l1W.0 -

L 11M - "1.0 12.4 643.5 - - - - - 11.1 0.2 11.3 - 642.1 12.7 U54.J -

IL _ _ * 1 1 * M U - 237.7 - 237.7 - - - - - U.S - U.S - 246.5 - 240.5

1. TITI 4. - 4.6 - - - - - 0.1 - 0.1 - 4.6 - 4.0 _

J. - 3471.4 - 3.071.4 - - - - - 121.1 - 13.1 - 3d".5 - 319".5

S. _n It 1mi 220.7 - - 226.7 - - - - 5.1 - -5.3 231.7 - - 231.7 -

Iotal" U3 S m9367.6 10623.8 314.3 2055.9 75S.2 667.9 3.2 1,473.3 30.7 462.6 12.1 763.4 0.471.0 11.914.3 356.6 fl742.5 125246

It. cm

A. *hI - 723.3 - 73.3 - - - - - 37.3 - 17.3 - 760.6 - 70.& -

*. wEI MITIt Mm u_ u1I 60 17.0 154.0 - 701.6 12.2 3.1 15.2 30.7 7.0 - 3U.5 65.4 164.9 - I5S.3 16.0

C. E(iJWt Imusyn 79.6 20.2 - 9.6 4.0 1.0 - 5.0 5.0 1.3 - 6.2 0.6 22.5 - 111.1 5.3

0. WIL1I1 UhIUWAl 336.2 92.6 - 459.1 1.2 4.6 - 22.8 23.8 6.0 - 29.6 466.? 103.5 - 511.7 24.2

10142 KCIM CUTS 1.053.5 990.4 - 2t043.9 34.4 8.7 - 43.1 5 .4 52.3 - I1l.6 19147.2 1.051.5 - 29101.7 45.5

1.1. 10,421.3 119114.2 314.3 22#549.8 719.5 696.6 30.2 1s510.3 406.1 454.9 12.1 875.1 IP1116.9 129965.7 35.6 24#91.2 1,576.4

F*uwrv 5. 167 17:S

- 72 -

Annex 3Table 3

IIAUWISECOND FAMILY HEALTH PROJECT

Su.maw Accowts bw Yti

Totals Includind Continu.'iies Totals Including Contirnicies(Local Cutter,w '000) (CUs '000)

1987 1988 1989 1990 1991 Total 1987 1988 1989 199O l991 Tobl:AXsXssX :S:::esg 222Z2222 ZZsZZ s =s==:=g : ZZZ =s=::=2 =sXaXX az= 2XX&ZX3 :s==eB =axaraz :sSZZzs

1. IWMSTIENT COSTS

A. CI'JIL M S 941Al.9 9.556.0 4,063.5 U4.3 459.5 24285.2 4W606.3 4,32.5 1 ̂ : 34 228.6 IO.1 11.021.23. FIMNITUI 406,4 689.6 490.3 51.7 - 1F638.1 194.2 309.1 208.0 21.0 - 732.2C. MATERIALS 914,6 1,119,6 1,903,4 29073.9 2,1M2G0 8,193.4 436.9 501,7 807.3 840.7 955.9 3,442.6D. ESUIPII)fl 671.6 487.0 532.1 37.4 17.1 1,745.3 320.8 218.3 225.7 15.2 6.7 786.7E. MENICMES 19422.1 190.1 20.2 21.4 22.7 19676.4 679.4 85.2 8.6 9.7 8.9 790.7F. TECIICAL ASSISTAMCE 2,3M5G9 538.3 240.8 181.3 192.2 3,538.4 1,139.8 241.3 102.1 73.5 75,4 1,632,06. ESIMN FEES 1,370.6 - - - - 1,370.6 654.8 - - - 654.8H. MONITORING r RESEARCH , EVALUATION 267.1 53.0 81.8 60,0 92.0 553,9 127.6 23.9 34.7 24.3 36.1 246.51. ACTIYITIES 9.7 - - - - 9.7 4,6 - - - - 4,6J. TRAINING 1,766.5 1.764o6 1,916.3 915.9 970.8 7,334.0 843.9 790.9 812.7 371.3 380.8 3,199.5K. OWSEAS TRAINING 366.4 100.9 27.0 - - 494.3 175.0 45.2 114 - - 231.7

Total IIJESTNET COSTS 19,222.7 14,499.2 9,275,3 3,905.9 3,936.2 50,9839.3 9,1834 6,497.8 3#933.9 1593.4 1.544,0 22,742.5:=::==:: s:ss:==: ::::=::Y =: = = : : : : : :== ====== = ::c::== :;::::=:

11, RECIRIENT COSTS

A. SAARIES 204.3 362.4 386.7 409.9 434.5 1,797.6 97.6 162.4 164.0 160.2 170.4 760.6D. UEHICLE WERATION AND MAINTENANCE 304.3 366.1 390.7 414.2 439.0 1,914.4 145.4 164.1 165.7 167,.9 172.2 815.3C. EOUIPIENT MAINTEWCE 4.6 31.8 69.0 80.9 83.0 269.3 2.2 14.3 29.3 32.8 32.5 111.1D. DUILDINI MAINTENNCE - 113.1 325.0 386.6 424.4 1,249.1 - 50.7 137,9 156.7 166.5 511,7

Totl REDLET COSTS 513.1 873.4 1,171.4 1291.6 1P381.0 5S230.5 245.1 391.4 496.8 523.6 541.7 2,199,7:x333gg*: :3S:::: a:S ss:$ S::=s: : :S::=38 38388383 8 ==::::: :=:==== 8::==:S8

Totl PROJECT COSTS 19t735.8 15,372.5 10,46.7 5,197.6 5,317.2 564069.8 9,428.5 6,889.2 4,430.7 2,107.0 M2065.7 24941.23s88s3:3 33.s.3ss a5333a3z 83zs23 83a8333 z 3 8 c38338s s3:. =3 :: Z== : c

Annex 3Table 4

SECIII FAuLT IEl UfCT

(Lwal Currenci. '0)

Price Cent iMUICLcasaw. caoI Physical Caamtndimcaao ------------- ------------ Total ladl. Coat.- … -------------- cal ----------------------- …- L. -Local (Exci. bties I Local (Excl. Miss I (Excl. buties I Local (ECxI. blitift IFor. Ezuh. Tos) Taxes Total For. Exch. low Taxes Toal For. Excl. Tas) Tixes Toal Far. tE-h. Tas) Tam Total

1. uWnTw CrTS

A. CML WM 7,713.0 11.2d.U 466.8 199442.6 771.3 1.t26.? 46.1 1,944.3 1149.8 1*676.3 72.2 23M.3 9*64.1 14,72.0 39.1 24.2K.2I. F1AIT 405.0 776.7 25.6 19267.3 4*.5 77.7 2.6 129.7 03.7 123.6 4.3 mA 617.2 M.0 33.0 I.U0.1C. alumli 49141.6 112.6 36.5 S94.7 41%.2 171.3 8.6 594.1 1v56.4 476.1 26.2 1656.7 59712.1 2,356.? 121.4 3.193.40. E IT1 1,309.3 - 17.0 1,36.3 136.^ 0.0 1.7 138.6 217.1 0.0 3.2 220.3 1,723.4 0.0 21.9 1SM3E. WENIS 1,394.3 - 13.9 1,406.2 139.4 -0.0 1.4 140.8 125.6 0.0 3.6 127.4 1,49.3 0.0 17.1 1J4A 4F. ITE .kY CCISTAW 3,179.1 - - 3,179.1 - - - - 359.3 - - 339.3 3530.4 - - 3,333.46. K513 FEES - 1w262.1 24.9 1,217.0 - - - - - 82.0 1.6 83.6 - 1,344.1 26.5 l.379.6N. I1S1I 9 Q4 0 E TICII - 475.4 - 475.4 - - - - - 73.5 - 79.5 - 553.9 - 53M.91. ITIVC TIT5 - 9.1 - 9.1 - - - - - 0.6 - 0.6 - 9.7 - 9.7J. 151316 - 6,142.8 - 6142.8 -- - - - ,1IV1.2 - 19191.2 - 7,334.0 - 7.334.011. M TUIM 453.3 - - 4S3.3 - - - - 41.0 - - - 41.0 494.3 0.0 - 494.3 1Total ?IIREII CUT1S 1i97]5.6 21647.5 626.o 4141.6 13,510.3 19375.8 40.4 2,946.5 3M132.8 3,638.3 109.9 6,331.0 23373.8 269661.7 793.9 56e3. W11. uIn CsUs

A. s"11m - 19446.7 - 3U446.7 - - - - - £5I.1 - 351.3 - n7.3 - l.797.33. OlUQ MOTIN Ma *IuMlEIW 1,213.2 30 .1 - 1.523.? 24.3 6.2 - 30.5 nS.9 T0 - 360 3.527.? 367.2 - 1.914.4C. EUWJ MIilIrEdW 159.3 40.4 - 19.7 8.0 2.0 - 10.0 47.6 12.1 - 59.6 214.8 34.5 - 269.3*. 11131 _En11 732.3 185.7 - 918.2 36.4 9.2 - 45.7 227.5 57.M - 295.2 906.4 M52.6 - 19249.11tt I -EII IS 2*16.9 1,90.8 - 4P0677? M.7 IJ.4 - 86.1 562.U 43.8 - 90U56.7 29738.5 2v492.0 - 523*.STotal M20642.6 2342.4 623.6 45,099.5 1579.0 1.393.2 60.4 3t032.6 1M-75.7 4e132.1 109.9 7937.7 26h17.3 299153.7 796.9 56W.9

F_euouw Srz 15 17:56

-74 -

Anex 3Table S

SECOND FMILY ALTN PROJECTP oNJct colpor-.rts b0 leaJ

'Local !urfrf,c¢ 0;C'

Lal1iast :its .-

,----,,-- - --- Loca

19r' 1938 *'' 1"75 iSl :C'ICrtr1 Usl '000)sS1s:: .:::: ass:::;; 5::.:::: :;zSZ :1:3S2sS * S:s:5

i.. PF 1P HEALTh CWE. ...... ................ .

r,fFll Y HEA^LTH CA. 304.'' ::5,e0 :E T7o 4o; ,4 467 3

EXTEN05,3 OF MIEALTH SERVICES :l65.5 :Sel,1: 3d145 , ;:: ,o '. ^ i t.4 41453.'3' STRENGTHENING Of THE HOSPITAL SYSTEM 50v 8 ::47.8 4 ' ; 30.6 5.:7co3 ; e38:

... ............................. ............ ......... ........ ............. ....... ----- -----

Sut-Total PRIRY WEALTH CARE 4°SO,c 5,474.' 34900.5 410.i 3t1' 15,15684 '"S ,2

t. W4A6EENT . MIOWER AND SUPPOlT SYSTEIS

; NkSIN EDUCATION S3' 1.067 0 i1. i 31.2 31.3 :4116.3 1i 0591

INSERVICE TRAININK 74' 20.2 : ";: 20.: .S5 t:61: 414.1

3. ESTAL.IUIEIT Of WVER CWAP:!TY 3c,4 - - 36.4 18.2

4. INPROWEENT OF M141NCT SYSTEtS,

SUPEfRVIS12' AD PERSNL 15' 6 85.1 t.1 - - 33<.0 163.0

S. HEALTH f'L*11151 tO, 21 1 :6 v. 6 0 64 I s 7 :1 Sz

6 FIIWKCIL PLANING 1443 1°6.5 141 10 i4.0 14i 7c5. 6 'oS7. WEALTH AND "ELTN I1 IWORM71ON0 236.5 11.4 31.o li . ;-4 it 151.1

S. RU PRIAJCTIWI AID U,Pt' .4 4o 'o ,4'. ii6 35.9 Io,;3.7 .

9. INTElATION OF SEIICES AT REGIONAL LEVEL :46.4 s1.t Sit. 61.( 6;.t 47:.4 :U. 2

Sub-lota. IIMAENT * HAOWNt AND SUF;OFT SYSTElS 3.307 i,;0 . 549.: 431.6 326.1 W23.7 3.326.3

C. FA4Mi 4EALTH.. ....... _ ..

rATERNL AND CHILD HEALTH 1141.1 56e.4 55e' :35.5 5i'.5 3.lO.5 11405.3

;. CHILD SPIACIM 395::.9 :>634.2 '45.0 :38.5 :36.5 i0401.1 31700,e

3. IJTRIT1ON * OH 89.e 75.: 13 .e 137.6 137.o 577.6 23.1.... ..... .. ... .. .. . .. __....... ... ... ___

SiL-Total FMNILY HEATH 5w26.6 3,:7, i .458.c 911.7 911.7 1129.: 57.794.6DI P8OJ!CT KIAIGT FOR PART A

... _...._....._._.._.. ......

1. PROJECT SIEW T 19443 2.4 e ..4 6:.4 :e:.4 :w93.7 1.496.9

Suti-Totil PJtCI IW NElNT FOR PIT A 1444.3 ;e:.4 :6;.4 ;e;.4 :42.4 24993. 1.496.9

E. h-TH TOH OTMI NINISTRItS..........

; UTTRITION THOM NO 374.0 354.4 35;.3 3v.1 3e3.0 1,006.1 904.4

2 VUNCTIOk. LITEIUCI IIIL 1M 1.127.0 611.1 1 0PO.1 1.024.3 it020.6 4.616.0 :400.03. YOUTH PROII 278.1 177.3 143.3 143. 143.9 36.: 443.14. ItlOTIIN, EUATION

AND CIUWICATION 301.1 20/.4 239.; : i ;:.9 1.194.6 597.3

Syi-ToUl HEALTH ThUSGH OTHER MINISTRIES 2,0001 1,35.2 1,765., 1746,.9 1755.6 5,705.5 4,352.1. .. .. . .. . . .. -_ -- ---- . ...... . - -_ ..

Totil IAIELINE COSTS 17411.: 121349.1 7,934.4 3.763.4 30439.4 45P097.5 22.50.1

Phwt: al COntUIiffIcIII l.120.3 95Y.l 531.3 214.4 19 .6 3,032.4 1.516.3Price Ccrtithmci. 1.204.3 2P0%3.5 1,972.0 1.t1.7 1#478.* 7,937,7 375.1

ow el OJCI tOSTs 15 97m.3 1s.37,51 0.74.? 597. 5,31.S 56O4'.1- :4941,.2gma2,11 "Ise &aa ss ans tg s a a:s;: a a*aaSg asg

T.,n ̂64.7 2ss.7 177.3 49.4 I1. 9.9 356. Fortia Exchig b 7.6 0.5452 4551.1 2463I.& ;t .3 : : . 1 I1.41M.9

__,_,,_,,_ ___- ..... ... . .. ... ... ... .... . . ............

F0tue* 5. 193'1756*

Annex 3Table 6

m"I

project (inr.tas by Te~ar

lmtUh 3nClu6sod ERL *PKuwe l0 otals lr.ck'jang CuntIMPIKaCS(Local Evivowv 'M) (US$ '000)

Mq ism I,3 MGo 19wi Total i,8r I9j 2939 i9Y 2991 lota.

A, P93OWT VMJLN COW

i. F'SlY VUAL1N t. 337.1 310.0 355.8 31.5 90.3 1,274.0 261.1 138. 1250.6 33.0 35.4 319.0E. XTENSIN V (00192 SW0IIUS 2.520.6 3,761.1 4,267.2 42,7.0 435.7 1.46 ,4.1.5. 10.3 1.2 2.9 .055.7

3. S1NMTKEI(N1 OF 1HE NWI100 STSTII 1.8. 2,853.1 629.5 40.3 43.3 6,451.3 19373.3 I2.6 267.0 16.5, 17.0 2.757.5

sub-Total.I fl' 2(0013 CIA 5,742.3 6,9?4.2.25. 579.3 569.3 IT.067.4 .27,43.6 MOM3. 2.727.4 234.8 223.3 8.532.2S. N V11WN , riNPWK AW 9DP3I STSICUS

3. 15i [NOTIN 1.0,3.0 1.381.1 40.2. 43.0 45.6 2.&I' 524.6 639.0 17.2 17.4 17.9 1,196.02. IUFICE 13A2NI36 816.3 24.2 25.7 27.2' 27.8 930.9 418.6 Mt. 10.9 11.0 10., 462.:3. ESTW3UUWIT OF WNIVI CWALI1T 38.7 38.1 1B.5j 33.54. IWUWIINI OF NOWAN1 SISY2STtS

WEEISIU MS PEESSIL 168.1 1021.9 109.3 330.8 80.3 46.1 46.6 173.0S. "TN1 PtMIni 36.0 74.4 1.3 10.4 11.0 341.6 41.1 30.9 4.. 4.2- 4.3 64.76. FIffiIA LANNMING 160.2 733.5 1'4.1 1P4.6 M1.7 952.1 26.51 106.0 73.9q 74.8 76.8 406.07 . 10"13 AS 310T1 EI1MNI 10iffWR2ATN 252.; 13.1 38.9 24.9v 15.3 334.6 120.3 5.9 16. i 6.0 6.? 154.?S . mm KlaS m WPF'ti 5,.4 5 48.5 190. 2 95.3 50.3 I.M3.7 466.0 245.8 80.6 79.2 19.7 891.4 I

9. 1311*UIIU OF SERICES Al IEGISMI 12VWt 265.2 94.1 100.4 106.5 2212.8 579.5 297.3 '4..7 42..6 43.7 44.3 251.13

Sub-1ot.l iNLmIVm . 33eW AN 52P92T S9115 .89.FNS7. 689.5 511.9 459.0 7.975.1 ;474. .087 4 735.9 180.1 1,620.0C. FUAlLY MEA1HN

1. MTU2( M 4013 C 'I1001 T 1,634.8 698.1 '31.0 748.1 773.0 4.605.0 8.0 317.8 310.' 2C.3 231.3 2,038.2C.HILD WAE133 4.020.5, 3,232.7 954. 2 373.6 343.0 8.9,23.! J.C7(7 1.4'1 1 404.7, 131.2 134.6 4.04:3

3. 331811200 . rmS 100.6 95.5 111f.6 117.3 209.7 790.: 48.1 47.8 '9.1 FO.7I 32.7 133.4

Sub Totll FANHy 31013 50, 5j. 9 4. 076. 2 1.673.8 1,261 .5i 1,145.7 14,317.1 -. 749.6 3.826.6 23 , 14.6 57 6.413.03. 13ACT INWIFI F21 '481 A~

1. 110.101 RI1u 1 2.33 304.8 375.3 344.8 365. 5 3,424.3 1.5 136.4 133.0 339. 143.4 1,553.2

Su6. 1.t.l P335E1 MI(D FOR FACT A -)GI. 104.R 175.3 344.8 365.5 3,424.3 M9., 136.6 1338.0 137,.3 343.4 1,553.2F. HEALTH T3133 09213 MINISTRIES

I. WM1I111TP O III CS 420.0 430.5 46331 494.3 528. -:3 0. 107.9 196.4 200.6 207.4 93. 02. 133(11533 311ERKV Io1n2 31N 35,25. 3 741.6 1.344.;- 1,422..7 1,.502.7.' 6. 268. 4 600.6 -, -. 589.5 7,669.33. 1341 PROMO 309.v 2.04.9 173.9 190. 201.9 1,307.6 143.0 97.2 77.9 77. 42.9~.4. ivFmTIiu (MWAI1SI

An CONNIMPICA110" 346.2 263.5 372.0 324.5 344.4 1. 59. 7 165.4 228.2 236.6 12 7.5 3_ 35.1 63.7

5.k, lokal N1AL 134 THROUGH O131 31N3508115 7,333.4 1,642.5 2,303.3 2,422.1 2,577.7 11122339 1,114.8 736.1 ?'9 -.0 932.9 1,013.1 4.3223

IGtal 111.1( COST! 19, 735..3 li37,25 10,446.7 I I1I .6 5,31.2' 52,61.00 9,423.5 6.339.2 4,430.?7 2.107.0 :,M,035.24,941.2

lubr...arh 5. 193 17:56

-- - m .-- - -- - -- - -- - - - - - - -- - - -

gotgww mm~~~~~~~~mz mmn

1. oiian171- -4 - -6.4 M - - - -. n - -

F. 1595 Muu 7.IW.3 4.16.0 3.64.4 62.012.1 - A. 3467 -2. I-311 S9WIMS36. -1.4L. -F In.9 41712 331..4 3.. 943 I -VA4. SAWA.1.IL iNO31011 64l2 29.4 - 1,0.1 - 3.2 1 - .16.? 140. am6.

wMiiSs ~~30.2 - 6464 3. -2 63. 1'7 64 111.16.6 -1. -n. 9.13.1K. SWOONS - 72. 1113 - - -3 -9. - -Ln. - 4- - 296 -- 4 41

Al lMTk- - - -L M. 9. -2 - - - - 4.D Mm in.. P2.1 - 2313 - 60.214. IAW4 8 -4. 60.4 462 475-41C. Uos 1- 14.4 6 C 44.1 44.1 3213 - - - 754 - 6.4 46."l10.1 l i 824.4111 11.671 1..9 74. 742 Ms4 164 13 11..82 619.! 24 2.,. 10.73. 17. 24. 1.76. J"1. .411946

ftnod C"iamgw 15.1 0l.9 -7. W.1 27.6 - - 2 I.1a -. W- 4sO?.? 12.1 -A aim W .a 16.5644 Cmmm 6ml MA. 31.1. 521.1 94. 757 .4 - 8 -M 6171. - 2.4 46.IL3 M 1.45.4 46. -L IU. 4.0 2L .1 76 30Ja 44.M7

I" lll~~ WS 1.17~47.4 SI.62 001.1 SAWS 71.7 W7. 44 141.7 17. 53.4 1.93. 396.3 72.64 3.7.M 3.9 62.6AM 241.1 6.1116.4 16WA M.IJ MW.

3m 9.0 96.4 113.6~~~~~~~~1 4.4 2.44 .4 - 54 .3 29233. 7.1 6.PS..M 1ob 437.9 4.67.6 2,744. %,16. 46.2 U.? 774.3 92.6 7118. 46.4 1.31.2 191.3: o 5~ .3 24" WA. 54144 33J 1.M16. 3417

(IahE7AThM amf ir lIt PUN1SM OF WrA.1f CNRpf~AKtT I

Inteu1 Quid . Oddipd f cuf f dfOfffctr AuDtor Acw"- Moin. Oule warit%,~yiim

L it (gliepw rovowel plim"m (Ef1 if ft a

afo. (lW)

W&- (M

lIIUN!EW tRW qIWJMI7AU9#. SllOJtIlRF- t IIAPT 2

|Prtnipall nret

at d~ (MCI hut. letrf 0. fog_Odf ldef SubuilM1ualmhuw peumtrsonnel Of Ibldif Fmdi7 Kw-view, I¶eMmc 1 iniI

OIfficer SrVikt Ifrnlth SIfh,r (1X1 fe 1

a ISrt IC

r ~ ~~~~~~ ct

| , s ,(NI-~ ~ ~ ~ ~ ~~~~~~~~~~~~~~W

-79 --

TABLE FOR MAP OF

PHASE I AND PHASE II DISTRICTS

PRIMARY HEALTH CARE PROJECT

Serial No. Sponsoring _of Stage Year Agency Names of Districts Remarks

1 1978-83 JOMs MOH Mzimba, Dowa, MWanza One district from eachregion chosen as pilotprogram: evaluation byWHO/UNICEF mission inJanuary 1982; workplanrevised on that basis i,July 1982.

2 1983-85 IDA Mzimba, Dowa, Mwanza IDA project supported iAxits first phase, thepilot program districts i

3 Mid-1985 GOM'S MOH Mulanje, Dedza, Ntcheu, Program this extended t,.Karonga, Neanje, Chikwawa 9 districts (cuLuuiative)

Government and IDA, soonthereafter in October1985 commissioned evalwtion of PHC program('83-'85) in the threedistricts of Mzimba,Dowa and Mwanza.

"New" New t

Districts Centers Gradations These districts arethi 'new" districts in

4 5scond TDA a. rkhatabay 2 0 the second phase of theFamily b. Lilongwe 2 0 primary health care"'ealth c. Chiradzulu 2 0 program.Project d. Runp;ii 1 1

e. Kas%.aju 1 1f. Mangochi 1 0

Subtotal 9 2

-80-

WAIT? ifSl MAP fl

PHASE I AND PHASE II DISTRICTS

PRIAY HEALTCAR PROJECT

Serial No. SponsorinSof State Year 4 *ncy Smes of Districts Imarks

'Old' DistrictsNeow M In these distrtets, PlC

Centers gradations program had already beenstarted in 1983 or aid-

a. ziba 1 1 1985; however, there hasb. Dowa 2 - been a need toc. Hwanza 0 0 strengthen the existentd. Nulanje 1 1 lnfrastructure with naya. Dedza 1 1 or upgraded healthf. Ntcheu I centers. At the szmg. Karong 1 1 time, three of the nineh. Chikwava 2 0 districts will be takeni. Nsanje 1 0 up for Intensive

retraining, based on anSubtotal 10 4 annual evaluation.

Thus, a total of 15Total 19 6 district are Included

in the Second Phase.

Districts Still To Be Covered

a. Mehinjib. Blantyrec. Salimad. 'achinga*. Chitipaf. Ntchisig. ?thota Kotah. Zomba__ Thyolo

3,--' , MALAWIPRIMARY HEALTH CARE PROJECT

0 Health Facility Locations

Makrwi I - Districts (3)" ,5,

l < \ ? Upgrode Health Centes (6)

- I s Malawi 2 Districts (15)*tNow Health Centers (19)

v &e.b. z Upgrade Health Centwrs (6)

Rivers5/ ^ @0 District Capitals

,'i RUMFP , , 1 ---------- District Boundories-~f - f ]> --- Region Boundaries

/ ~ >g - - Internotionol Boundariesa is k *t i~~~~~~~~~~'00r to N"im report fror list of

/.4o _ 6 \iout of ths fiften, s.0 followingsix districts ore take-, vp under te

, _' .*t ............ Second Protfct fo he PtHC proPraMt4~lU for th first time. Nkhoio &ay,

MZiM^A L Lslon. , Chrodzulu, Rsmphi,A Ai A. Kosungu, Mongoch. The otO'e niner 3 g oJ>y ,' / include hre taken up with IDA

, / } ossistance under the first proeclt. and2C 7 . p si by the Government in 19W3 '

ZAMBIA -{K.LOMAiiA5 0 20 40 60 so ,OO

,/ **1 :I~~~~~~~~~~~~~~~~~~~~~~~~~~~~0A io -P^ . C

) '.a , J.WO

/ CC NPFA I

.t : , \ ~~~~~~~M O Z A M. B I Q U E

r ON W ._.7

"It 1g.+ 'h 1'.W fIK NIL

A y 0 A:

)M-AAMB OV* i -

'.,d'3*,44*,C&,1-T,,A\ GS

o ' wi 'w5o ' wi t30 r

rp,,rr a' ., trrwt a '_

A A N A ~ iMMA

~~~~.~.J Ni O ZA MB IQUE /°Lon/

r'AN2AiA AA 19v,

't >< ,V{V/ V fS 2

js~t -4 v N.'.

|~ ~~* _' 5 As*_tOW$!

I'd .h -- ' * S-" ) K 3d'F>XtA \

8G;eA [ ~~~~ 5s ts ¢ |_ _ _ \,> g r , . . . .,ANUAe-19S