―닌＊! CIARRENCY E-OUffA~ US$ 1.00 = CFAF 250 ABBREMATIONS AND ACRQNM A~ ~i*tion d'E~t& du g=~ Phy~ du T~A~uuon Mantla du wficients Auditifå du Tched AIDS or BAD Alrican Development, Ban~ Aft~ de Devot~~ ANDAT A&Miation Nationåle du D69k1~ Auditifs du T~ ATBEF Association TÖ"~ do Bl~ F~ ~ CI) Buruu dMude et do Litison dA~ Ca~ et D6v*IoM=nt BET Borkou - Ennedi - ~i BIEP, Bumu Iamr~ tiei Etudöe et PKOgrar^ BSPE Burcau Statistique, PUMIIoadm et Etudes CAMS Conuté Allo~ ~ mo de Sw~ CFPA Ca~ de Formation Professionella A~ CNAR Cimtre National d-App~ go et de R~ *tionMO National Center fot Röbabilitation CNNTA Centre National de Nutrition et do Tochnologie Afimentaim CREN Centre de RMabilltation Ed~ et Nutrionnelle DAF Diroctiott Administrativ* et Fmancibre DPKLAM Directorate of Pharmaoics and Låboratoriös DSBED Direction & la Ståtlatique et tin Etudts Bx~ uu et Dd~ phiqua EDF~ VI Fkropöan. Developmönt Fund VIMM Fonds Dum~ de D6v*kpamm EDL Emntial Drugs List EDP ~ al Drup Program EEC European Economic Community ENSM Ecole Nationale de ~ Påbilque et du ~ c* SocialMö National Hospital Eff Expandod Pr~ of Immunkatioft FAC Fönda d*Asdmm et Cw~ FAO Food and Agricultural Or~ ation m Food for the H~ International FRC Fmancial Reltabilitation Credit om Governmant of Chad lm Helen Koller International INPI) Health Persomiel Devolopment ICO International Cooporatim Office IDA International Development Aumätton IEC Information, Education and Co~ cation ffs Jästitut Tropical Sulm MASWI) of Social Affain and Wowen'a Dövelopment MCHIPP Maternal and Child H«WamHy 0~ MOD Ministry of Dela= MOH M~ of Health MOHSA Mnistry of Héalth am Social MOPC Ml~ re du Plan et de ta Coop~ MOPHSA of Public HeaM and Social AMts MSF M~ Ins Saiis Fronam NCKM Non Governmental Or~ ations NCHS National Center of Mcalth Sta~ NHDP National Healtfå D«dopm= PI= PASP, Pharmacia d'Approvisiomw~ du Se~ Public pm Projet ~ et Red~~ In~~ PEV Programmes ~ de Vaccination PHC Primaty Health care PS POM ~ 118118 SECADIEV Secours Cath~ et D6veMp~ SIPT Soc16t6 Pharma~ du ToMd SAfi-DF sam Måtemik Iftånfile-Bifl~ SPONG Secrétariat. Perm~ des ONG& SM S~y Transmitted D~ TOA Traditional Birth AM~ TEMt Tu Evangelicat Ifission Am~ TFR Total ~ Ity Rate UNAD Union National du A~iauons ~~ de Divelop~ UNFPA United, Nations Pund for Poputalion Activilles USAM - United Statts Agency for International Development VA - VOluntarY Avacia WFP - World Food Program WHO - World H" Organization TABLE OF CONTnTS EXBCUTIVESIUMM ............................................. 1-vill I. INTRODUCTIONM ................................................. 1 A. Overview .................................................... 1 B. Background and Context .......................................... 2 C. Donor Collaboration in the PHN Sectors ................................ 3 II. P P L T O .. ................ .......... ....... ........ ...... 6 A. Demographic Situation and Trends .................................... 6 B. Implications of Population Growth .................................... 7 C. Population Policy, Institutions and Program ............................. 8 D. Family Planning Services .......................................... 10 II. UEALTH ....................................................... 12 A. Health Status ................................................. 12 B. Specific Health Problems .... ..................................... 14 C. Health Policy and Health Pl nning .................................... 17 D. Institutional Context ..... ........ 4.........6.......... .........4.... 19 E. Organization of Health Services ...................................... 24 F. Utilization and Quality of Health Services ................................ 28 G. HealthManpower ............ .................................. 29 H. Pharmaceticals ................................................ 34 I. Health Sector Expenditures and Financing ................................ 37 IV. NU R T O . .............. ......... .......... ......... *..... 44 A. CurrentNutritionalSituation ........................................ 44 B. Policies and Institutions .......................................... 48 C. Nutritional Programs and Interventions ................................. 49 V. RECOMMENDATInS IN HEALTH. POPUATIO AND NTION. . .. .. .. . .... 51 A. Slowing the Pace of Population Growth ................................. 51 B. Improving the Quality, Coverage, and Cost-Effectiveness of Health Services .. ..... ... 52 C. Mobilizing Sufficient Resources for the Sector and Increasing Cost-effectiveness ....... 56 D. Alleviating Nutritional Deficiencies and Improving Household Food Security Measures ... 57 This report is based on the findings of missions that visited Chad composed of Mesas/Mes. E. Jmrawan (Mission Leader), A. Bach Baouab (Population Specialist), B. Boostrom (Sr. Public Health Specialist), L IUfanda (Nutrition Specialist, Consultant). The health expenditures section is based an a report prepared by Jean Perrot (Health Economist, WHO International Cooperation Office, Geneva). The report was processed by Ms J. Laygoaie. L Of TEXT JABL III-1 Principal Reasons for Consultations in Health Facilities by Year M-2 Health Personnel by Qualifications and Status In 1990 III-3 Health Manpower I-4 Donors' Intervention by Geographical Areas rn-5 Health Budget Trends III-6 Public Sector Health Expenditures 111-7 Trends in Per Capita Health Expenditures II-8 Proposed Budget for 1992 III-9 Health Expenditures included In the PIP r-10 Breakdown of Health Expenditures in the PIP ANNEXES 11-1 Population Repartition by Sex and Age Group Summary Indicators of Age Structure 11-2 Population by Type of Residence, 1970-1988 Population Density by Geographic Area Project Size and Growth of the Population 11-3 Projected Population by Age Group Health Manpower by Specialty I-1 Most Frequent Health Problems Health Problems Seasonal Variations - Year 1990 III-2 Number of AIDS Cases per Year AIDS Cases in Chad in 1991 - Age and Sex Distribution Sero Surveillance by Sentinel Sites HIV Surveillance by Sentinel Sites, March-December 1991 III-3 Social-Health Pyramid - Administration and Social-Health Facilities 111-4 MOPHSA New Organizational Chart - Central Level MOPHSA New Organizational Chart - Prefecture Level MOPH Former Organizational Chart Functions of MOPHSA Directorates II-5 Health Information System 111-6 Health Facilities by Affiliation Health Facilities and Beds/Places by 100,000 Inhabitants and Region Health Facilities - Conditions of Buildings, Water and Electrical Supply, and Communications III-7 Public Sector Health Personnel by Prefecture rn-8 Health Expenditures and Financing IV-1 Caloric Intake Average Quantities of Cereals Consumed at the Time of Survey IV-2 Prevalence of Severe Malnutrition in Selected Towns and Villages, 198691 CHAD POPULATION, HEALTH AND NUTRITION SECTOR REPORT Executive Summary In 1993, about 250,000 babies will be born in Chad. At least 30,000 of them will die before their first birthday; another 45,000 will die before reaching age five. Those who survive will have diseases that are easily preventable; most will die before reaching 47 years of age. More than 2,000 babies will be orphaned in 1993 because their mothers died of pregnancy-related complications. Most of these women wanted to know more about contraceptive methods, but never had the opportunity to use them. CHAD'S SOCIAL INDICATORS IN COMPARATIVE PERSPECTIVE Chad cannot maintain its current high rate of population growth and poor female education and expect to achieve sustained increases in well-being. "Investing in people" - promoting preventive health care, population programs, and female education - must be a priority in Chad's future economic development strategies. While defining these investments, the Government of Chad (GOC), donors and Chadian communities must keep in mind that social indicators are linked. The high level of fertility, for example, is negatively related to the mother's and children's health and has a long-term negative impact on female education; the high infant and child mortality rates and lack of access to contraceptive methods lead families to have more children than they ultimately want. An effective human resource development strategy needs to take into account the interrelationships among health, population, and education programs. Chad's demographic and health indicators are deplorably low and lag behind most low- income countries. While Chad's total feriit rate of about 6 live births per woman is among the lowest in the SSA region (the average is 6.6), it is very high by world standards. Chad's population, having nearly doubled during the past 30 years, is expected to double again over the next 20 years. Other demographic and health indicators are even more striking: the crude death rate of 19 per 1,000 is about twice the average of low-income countries; life expectancy at birth (47 years) is well below the average for SSA (51); maternal motat is estimated at 700 live births, compared to 630 in SSA. Children's health and nutrition indicators are among the world's worst. The infant mortality rate is 127 per 1,000 live births compared to the SSA's average of 106. Surveys show pockets of severe malnutrition throughout the country, particularly among children 0-5 years of age; more than a third of the children in one of the Southern provinces is below 80% of standard weight for age. Malnutrition may be attributed not only to household food insecurity but also to conditions that can be readily targeted including poor weaning practices, lack of clean water, and poor sanitation and hygiene. DEMOGRAPH[C TRENDS AND IMPLICATIONS OF RAPID POPULATION GROWTH Even assuming a modest decline in fertility, implying a modest increase in contraceptive availability and use, the poMation of Chad would more than double over the next 20 years. The problems are further exacerbated by the distribution of the population (70% of the population live along the rain-fed south and southeast), the high urbanization rate (the population of N'Djamena has increased five-fold during the period from 1960 to 1990), and social factors such as the low literacy among women. - ii - Fertility reduction would have a number of beneficial impacts. It would: (a) Improve maternal and child health; (b) enable Chadian women to exercise reproductive choices and space their children; (c) alleviate poverty at the family/household level; (d) decrease the burden of dependents under 15 years of age; and (e) improve the use of Chad's limited resources and help promote development that is more environmentally sustainable. In order to slow down the rapid increase in population, it is important that the GOC give priority to the following: - Establish a Government Coordinating Body for the development of a Population Policy. Create within the MOPC a Population unit to act as the Secretariat for poie developme and r plannin; (this was emphasized by Mr. McNamara in his statement to the Global Coalition for Africa, in May 1992, in which he proposed a program to accelerate reductions in SSA's population growth rates) - develop a natoa FP atW and a mlt-a plim of to increase access to PP services; training of health providers in MCH and PP should be emphasized; and * promote a multi-media approach and participation of NGOs and the private sector in IEC activities. THE HEALTH SECTOR Health Conditions The principal causes of mortality and morbidity are infectious and parasitic diseases, pregnancy-related conditions, and malnutrition. It is suspected that a large number of Chadians are afflicted with Sexually Transmitted Diseases (STDs)(an explanation for the lower than expected fertility rate) and AIDS. The number of AIDS cases has practically doubled each year from 1986-1991 (130 cases as of June 1991). There is clearly a need to undertake a rapid assessment of the situation in the country and accordingly, determine a plan of action. The leading causes of illness and death are all preventable, some more easily than others. Most of the problems of the Chadian population (80-90%) can be dealt with by a basic package of health services (including control of communicable diseases and FP). The Government should focus on the provision of these services to the maority of the population. Safe motherhood and improving IEC methods should be emphasized. Health Poncy The GOC, with the support of major donors, has taken steps in recent years to coordinate interventions in the sector, and to develop plans aimed at increasing coverage by appropriate basic health services. Within this framework, the Government encourages donors to take charge of at least one complete health district (Chad has 46 districts) and to focus on its development and on improving the district's capacity for planning, organization, and management of health services. However, in spite of the public commitment to decentralization and to PHC, the sector remains dominated by vertically- oriented programs. - il - As a Nadonal Health Development Plan is being prepared In the context of a Health/Social Affairs Round Table (scheduled for January 1993), it is essential for the Government to coordinate with donors in order to elaborate a viable and realistic plan of action for the sector. Heath Care System This is a three-tiered system operated by public (65% of total health facilities), church (24%), and private (11%) health facilities and characterized by overall low crag , p access, and imited rsou throughout the country, there is one hospital or health center bed per approximately 1,300 people (600 in Gambia, 775 in Senegal, and 1302 in Mauritania); to reach a health center, about 60% of the population need to walk for at least two hours. In spite of abundant health problems, most public primary health facilities are under-utilized due to difficult access, a lack of medications, and to the public's low level of confidence in the quality of services provided. The mix of services available does not adequately promote preventive medicine. There is a severe shortage of ualified health care personnel. Their geographic distribution is also strikingly distorted: about 66% of 164 physicians and 64% of 101 midwives practice in N'Djamena. Training capabilities are mediocre and the medical school is the subject of controversy as donors agree that Chad should pursue a policy of overseas training. The lack of health personnel olanine is one of the principal problems revealed by the personnel data. To deal with these problems, the GOC should decentrali the mangmM and p n of health services to the provincial and distrct level and ensure that the basic package of health services is accessible to the majority of the population. Accordingly, these services should be available at the health center level or below and should stress preventive measures. The Iharmacencals is characterized by: (a) a monopoly of Importation and distribution in the private (for-profit) sector; (b) a weak and disorganized public sector with a heavy dependence on donors; and (c) a voluntary sector which partly meets the country's needs and has had successful experiences with cost recovery. There is clearly a need to establish a national drug policy based on: (a) elimination of the monopoly; (b) establichment of an essential drugs program; and (c) decentralization of distribution and cost recovery. This will require the central drug administration to be strengthened to enable it to play a leading role in olicy-makina and quality control. Health Expenditure and Financing A review of Central Government health expenditures reveals the following: (a) Health has absorbed a relatively small share of the financial resources directly controlled by the Government (4% of GOC budget over the past few vears). In 1990, the GOC spent $1 per capita on health (Niger spent $4 per capita in 1989). External aid has represented about 80% of the country's health expenditure ($3.5 per capita) and households' out-of-pocket health expenditure is estimated to be $1 per capita. Therefore, per capita total health expenditure is about $5.5 ($24 for Senegal); (b) the allocation of Government spning has favored curative health services ad Za. The Department of Hospitals and Urban Medicine accounts for almost 50% of the personnel costs, and does not reflect the Government's stated intention of according priority to IHC. - iv - (c) AW=ropriations for drug purchases. which were very low. were not used because of unavailability of funds. When external aid and private health spending are added, the picture still remais skewed in favor of curative services as well as recurrent expenditures. Aid can no longer be regarded as a temporary replacement but as a necessary complement to the Government's limited resources. A comprehensive study of health financin, is necessary to develop a realistic plan for the health/social affar&to. ALLEVIATING NUTRITIONAL DEFICIENCIES Malnutrition is a serious problem in Chad, especially in the rural areas. While poor weaning practices and food shortages are the leading causes of malnutrition, other causes are a lack of clean water, and poor sanitation and hygiene, resulting in high rates of diarrhea, a major killer in Chad. Malnutriion should be fought primarily through education and Dreventive measures. The lack of a coherent nutrition policy severely handicaps Chad's ability to address its nutritional problems. Activities are isolated and performed by various agencies and ministries with little knowledge of each other's actions. Clearly, it is important for the Government to establish a pliey framework to fight malnutrition and accordingly. strengthen nutritionai activities and integrate them into existing prorams. Health and social services personnel will need to be trained accordingly. CONCLUSION: PRIORITIES IN THE PHN SECTOR The GOC needs to give precedence to: (a) Slowing the rapid pace of Roulation growth through strengthening population policies and programs, especially family planning, to enable couples to space their children; (b) Improving the quality, coverage, and cost-effectiveness of health services by: (i) decentralizing the management and provision of health services to the provincial and district levels; and, (ii) strengthening the planning, management, and support/supervision capacity at the central level, and decentralized implementation capacity at the prefectural levels, to build upon the promising start made in the past, especially with regard to: - developing and applying protocols and standards of treatment; - manpower planning, career development, and pre- and in-service staff training; - management and distribution of drugs; - information, education, and communication (IEC); and - control of key diseases, including AIDS. (c) Determining how to mobilize sufficient resources in order to support and sustain population, health and nutrition services whi allowing for development needs and at the same time, decreasing Chad's extreme dependency on external donors; and -v- (d) Alleviating nutritional deficiencies and improving household food security measures through the development of a national nutrition policy and implementation mechanisms; maintenance of an institutional capacity to respond rapidly to emergency information needs; water supply and sanitation; agricultural support; and integration of the health service aspect of nutrition into a basic package of health services. -YI- St1MMARY MATRIX '::{{{:: •: • :l' 4г::::::.ц::. v:.ч,•г, •. г•::чх . :}. `}г}:4:ц:{{; . г ; {:: . ..4г.w:.: .'L} .. .}:х{•:{.}:м::,и tiгг{.г:{ vгч:.{{{{ь•Ч?ц':::: . :..+C...h....... 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'•� �: �� .й. �i��{i- �.�iС��ш:- . ' • ;': :i: . �� - -�. 1!!!�'. .._ .Е^i'._. ...._-. . i .•.. .�. . ..,.�4L<. ��,.:•°Ls"е'°fй8а`•R'..г�,.. .+..-...... ... ;�.�!:•-. . . ;'t'.�У!R?f:-� ki�fr��'� , `:'�'`k�в��' .. . , J.. г "j`::.k�. д•�у,г' . . . �/'� � • ч г•';S , •{} • •• • л ' ч • '�ч • .н¢.�.г,.� +�.�� �. ' г л:: �; , цS•. 1К 9NOI,L'VMi�1lWQ�I • . •. • . • . ' S�IL;� :.•:�::'. • ', ';:' ��:•,.::•г,• •. . . .. .ч . . . ' ���А - A. Ckemig& 1.01 Despite official pronouncements, health has not been a national priority in Chad. The Government has set, and reaffirmed on numerous occasions, an ambitious political, social, and economic agenda, but the constraints have been too great. Human resources development, as measured by demographic, education, and health indicators, continues to lag behind most low-income countries, and Chad's extreme poverty and crying development needs present a major challenge. As the country grapples with difficult short-term problem and strives toward sustainable longer-term development, progress on population, health and nutrition Issues will be more crucial than ever. Itere are reasons for both hope and concern about the prospects for achieving that progress. Among the reasons for hope are the following: (a) Chad's development potential in agricultural diversification, mineral resources, private sector expansion and community participation; (b) The Government's commitment to a reform program aimed at stabilizing the economy in the short- to medium-term while creating the conditions for a resumption of self- sustained growth Mi the longer-term; and (c) The great self-reliance of the population, and the generous response of the international community to suitable development initiatives. Among the causes for concern are: (d) The country's unstable political environment and the resulting debilitating effects that the security situation is having on all aspects of life in Chad; (e) The serious economic situation reflecting yens of domestic turmoil with a negative impact on production, trade, fiscal revenues and budgetary performance; and Chad's low and over-stretched absorptive capacity, particularly in the social sectors, due to the rapid expansion of the public investment program in the late 1980s, inadequate operating budgets of the technical ministries, and mexperienced and poorly trained personnel. 1.02 The challenge facing the Government of Chad (GOC) in the years ahead in the areas covered by this study, is how to improve social sector services and significantly improve the quality of life for its people by building on its strengths, and at the same time, managing the various serious obstacles to progress. Clearly, there is much the Government can do, provided it builds effectively on the lessons of the past in the health and broader social services areas. While the difficulties are considerable, the challenge can be met through skillfW policy choices and effective planning and implementation measures. 1.03 This PHN sector review is Vart of the gagM Wleviation focus of IDA's ass to Chad which concentrates on improving welfare and the prospects for long-term growth by, among other intmentions, increasing the accessibility and quality of basic social services. Its objective Is to help Bank suff to better understand Chad's current PHN situation and thereby to contribute more effectively to the process of strengthening the Government's capacity in policy development, planning, ma agemeat, and service provision. The review will help define IDA's strategy for the sector and can be used to introduce or better integrate PHN issues into IDA's policy dialogue (both within the sector and on a more general -2- level). Information provided in this sector report, along with experience in implementing the health components of the Social Development Action Project (PADS - Cr. 2156-CD), can be used in developing the future health/population project. Therefore, the audience is primarily the country team and particularly those members of the team working in the social sectors. Since there are several reports on the various aspects of the health sector in Chad, the usefulness of this report is not so much to provide additional information, but rather to synthesize existing information and use it as a tool to facilitate the dialogue with the G as well as with the donor0cmmuity-another possible audience for this report. ............. Box 11 Povetty alleviatlin is the prndpal. o1WectIi of IDA' a sitac trategy inat th cre prga qualty or bati sodda sevics increasitig incomes thequ goAvity incress4 a iproved icentives in the glO~ituira setor wbath the eity thetl gopu*lop wad prmoting employ aet genaeratiu ad aniepenercipby nouagn th rvi0slea of service by the^ privte se.en, and supoting ths reallocation ofpbi sedttesu toards develpint pupool hisposed food seenuty is as integal ev*tate the adequay of inaidwio as poetnCa slid. a pot ade onsttngboldg ihh prpae next r Pri4ayidlesi ar'hn istngformation.is insufele*fo eval.uating alIative povet betweenra t when its ewdrgosadfrdaatrdaW eal rus Howevers it is eviden,at ther ar infcn ipttd wtenth.otagoigae fhda h ~developed occ.nunwitty oraaiosa beterntwork of ivatepoies fuetonadhat sevie. hreoe,i tecotxtfprjctpeprtii, 11Ai actvely exp ori fh n4eedfor alternatv sevie elvey ppoabe for th. e ftiess-devoed area which sa 1b muor suply4ien d dependent n Goenet oretralspot Sore World Biank~ CAr g onnsder a .n29~ I992 B. Background and Context 1.04 When Chad gained its independence from France in 1960, it was poorly prepared in terms of infrastructure, level of human resources development, and management capacity. Between 1960 and 1977, the country experienced relatively steady economic growth, largely due to the export of cotton - its main crop - which was an important source of government revenue. A drastic downturn began in 1977 as the country struggled through a series of external and natural events: the 1979-82 war destroyed most of the country's physical and administrative infrastructure and reduced its economic activities, while the prolonged drought decimated the livestock herd, reduced food production, and displaced a large portion of the population - mainly from the northern and Saharan zones - to the south and the capital city, N'Djamena, as well as to neighboring countries. In addition, the collapse of the world market price for cotton in 1984-85 caused a severe contraction of the economy. 1.05 Today, Chad presents a vivid example of a country where deep poverty and a lack of development advantages would challenge even the most dedicated and determined government. It is one of the poorest, least developed countries in the world, with a per capita GNP estimated at $190 in 1990 .3- despite the GObvernment's efforts to stabilize the economy. Yet, Chad's most intractable development constraint is non-economic, i.e., recurring political instability and domestic strife. In 1987, the Government put in place an emergency program to prevent the cotton sector's collapse and avert potentially disastrous political, social, and economic consequences. The cotton reform effort was expanded into a comprehensive adjustment effort supported by IDA and the IMP under the Financial Rehabilitation Credit (FRC - Cr. 1945-CD) and the Special Program of Assistance (SPA). Progress was generally good for sector reforms which included, in addition to cotton, policy reforms in transportation, livestock, trade and education. Progress on reforms to improve public sector management was much slower and by mid-1990, adjustment performance was waning particularly in the level and composition of government expenditures (an overrun on military expenditures increased the budget deficit from 2.3% of GDP in 1988 to 4.1% in 1989). 1.06 The adjustment process suffered a serious setback after the change of Government in December 1990. The economy is currently depressed and enterprises in the formal sector are in danger of collapse; the public finance situation is extremely "tight" with Government paying civil servants and the military irregularly. The main problems have been serious overruns in military expenditures and the civilian wage bill with reduced revenue performance, particularly for customs.' The Government has categorically stated its commitment to continue the adjustment program launched in 1987. However, the adjustment process suffered serious setbacks. 1.07 Meanwhile, the series of disasters the country has experienced in recent years has had a profoundly negative impact on all social groups; many have recently migrated to N'Djamena from the drought- and strife-stricken regions, and are now living under precarious conditions. They have all suffered, to varying degrees, from a temporary lack of productive activities and public services, and from a lack of transportation and a deteriorating infrastructure. The extent of poverty, the low level of social indicators, the ever-present risk of widespread food insecurity due to drought and poverty, and the deterioration of the physical infrastructure are compelling reasons for maintaining dependency on external aid. With the help of the international community, the Government is committed to staying on track with the reforms and concomitantly redirecting social policy towards efficiently promoting the rehabilitation of the country. C. Donor Collaboration in the PHN Sectors 1.08 Since the return of civil order in Chad in 1982, the Ministry of Public Health's (MOPIf primary task has been to reestablish a minimum level of central administrative capacity and to deliver basic health services to the Chadian population. The GOC has called upon donor support in this effort. The emphasis was rightly placed first, on "getting something done," and second, in formulating well- designed strategies. As a result of this fragmentary approach to service delivery, the impact of these efforts has been lessened. However, in recent years, with the support of major donors, the GOC has taken steps to strengthen health services planning and management and to coordinate interventions in the sector while increasing coverage by appropriate basic health services. 1 Civil servant salaries are two to four months in arrears in N'Djamena and much longer elsewhere. Arrears to suppliers are building up and debt service has gone unpaid for all but the IMF and IDA. 2 As of 1991, and as a result of its reorganization, the Ministry of Public Health (MOPH) is called the Ministry of Public Health and Social Affairs (MOPHSA). Therefore, both acronyms may be used in the report accordingly. -4- chedhI fiy4 ih n adiit s dA npndto0% ofGCDP. idcodiaion is Merlbi sedl.thliancifer DA&1 ih European Comanity and Franc m the mos haorant dwoowi Cha. Iof stngnt,dn have vichb& well t1der Th definition of scortatge lmwielphsebye noun Gvermet alk $DAU wiioliatasupportdisproces ad takth lai a th e etors, AU ND4edRound Table, whchbhsiset in November 1990, is th Inacia aid soordinatinadhnimad haworked pa notvlthtwshe apeies of sectoral Roind Tables. Local aid couninaton wda lbotvelythouh fuforml alshansms oneae wihichb inerits Mattto in the Govramntis limirangent ofthei sabthia e1a asitac2had reeives. Therehave~ been a M.m..... M U M dris r eeitp t bregrmpofMobt; otle let~M 4@ daTd ad oniIz sevea occsles, anwthi 1.09 Currently, Chad depends upon donor assistance for over 80% of public health expenditures. For many years, NGOs, mostly church organizations, have been providing medical services including medicines. Beginning under the 6th program of the European Development Fund (EDF VI) (in nine Sahellan provinces), and continuing now with parallel support from other sources (Germany, Italy, Switzerland, France), donors have supported the development of MOPH health services at the provincial level, on a province by province basis but within a common framework. Within this framework, the Government encourages donors to take charge of at least one complete health district and to focus on its development and on improving the district's capacity for planning, organization, and management of health services. The EDP VI program has taken up the leadership role, providing technical assistance (one person per province, as an assistant to the Provincial Health Director), along with annual national training seminars for the Provincial Health Directors and technical training for selected members of their staff. The Swiss Development Corporation is providing similar support in the peri-urban area of N'Djamena and Chari-Baguirmi, and other donors are providing (or planning to provide) such assistance in the remaining provinces. The African Development Bank has provided much needed support to the central level of the MOPH. 1.10 A UNFPA-funded project supported the development of family planning (FP) services from 1985 to 1989, with a particular emphasis on the clinically-focused Assiam Vantou Center in N'Djamena. The follow-up UNFPA project, executed by WHO, began in mid-1991 with the arrival of a WHO staff member as a temporary PP advisor. The project is expected to develop FP services in Moundou and Abdch6 and to deal with PP policy issues at the central level. 1.11 UNICEF has been praticularly active in immunization and oral rehydration therapy programs, in addition to nutrition and information education and communication (IEC) activities. UNICEF also participates in financing the AIDS program. -5- 1.12 A USAID-financed project to strengthen the MOPH's planning capacity, completed in 1989, resulted primarily in the development of a health services statistics collection and tabula- tion/reporting system, but also helped the MOPH define the functions and activities of the various levels of health services and health services administration. USAID's Chad Health Survival Project includes further support to strengthen health planning and to provide assistance to child survival activities. 1.13 The Af DB-financed Projet d'Etudes et de Re4forcement Institutionnel (PERI) includes support for health sector studies and institutional strengthening of the MOPH. In the first phase of the project, a series of studies on Chad's health sector was carried out. The studies indicated the seriousness of the health sector's problems while proposing a number of projects for AfDB financing. They also demonstrated the GOC's lack of integration of available information on health sector planning and the absence of a coherent sectoral planning framework. 1.14 In addition to financing health sector studies, the PERI has provided technical assistance for institutional strengthening of the MOPH (para 3.32). The progress, as summarized in a recent PERI report,3 reflects the long-term view and approach taken by the MOPH with support from the organizational and management component of the PERI, a very positive factor which increases hope for the long-term development of Chad's health services system. In 1989, the Ministry of Plan, through UNDP, designated WHO as the Executing Agency to assist the GOC in preparing the Round Table for Health and Social Affairs. The preparation is being carried out in collaboration with AfDB and in consultation with other donors involved in the sector (para 3.30). 1.15 This report is based on available health sector studies (AfDB, WHO and others) as well as discussions with Government officials and major donors in the country. It is organized along the three subsectors - namely, population, health and nutrition. Section II describes the demographic situation and trends, the implications of population growth, population policy, institutions and programs, and family planning services. Section M describes the health status in the country, and examines the various components and determinants of the health system. Section IV provides an analysis of the nutritional situation in Chad, including the policies and institutions, nutritional programs and interventions, and the role of donors. Finally, Section V addresses the recommendations in all three subsectors and summarizes them in a prioritized, time-phased approach. PERL Jid 1991. Ministre de la Santd Publique, RdpublIue du Tehad. Rapport Final, PERL BAD/CHEMA/SCET.T/MSPASITCHAD. -6- H. POPULAION1 A. Demogra Situation and Trends 2.01 Data and Information sources on Chad's population are scarce and unreliable. There has never been a census taken in the country, and current demographic data are based on the results of the 1964 partial demographic survey and the administrative census of 1968 conducted in ten of the 14 prefectures in Chad. Although a population census currently in the mapping stage will provide more reliable data by late 1993, the absence of systematic vital registration will continue to prevent the more precise estimation of demographic trends for the country. Thus, mortality and fertility estimates derived from the 1964 and 1968 surveys will continue to provide the basic data for population projections until the census data become available. 2.02 Chad's population, which stood at roughly 3.0 million in 1960, has nearly doubled during the past thirty years. In 1990 it was estimated at 5.6 million, assuming an average annual growth rate of 2.48%. The age structure of the population is similar to that of other Sahelian countries with more than 50% of the population under the age of twenty. The age pyramid has become broader during the past two decades with the proportion of children rising steadily from 9.9% in 1970 to 17.3% in 1990, and the percentage of population above age sixty remaining constant at 5%. As larger cohorts of women enter childbearing age, and given the likelihood that the current high level of fertility will be maintained for several years, there is a built-in momentum for rapid population growth. Current estimates based on Bank standard projection assumptions suggest that the total population would increase to 7.4 million by the year 2000. Even under the standard fertility decline assumption, which implies a modest increase in contraceptive prevalence, the population would more than double over the next 20 years. This situation is also further exacerbated by the distribution pattern of the population. Although the average population density is low, it is very unevenly distributed over the territory. Population density in 1988 was 4.2 inhabitants per km2 but varies, however, from 0.2 in the desertic northern provinces to 42 in some of the more densely populated areas around lake Chad and along the rain-fed south and southeastern parts of the country where nearly 70% of the population live. 2.03 Chad is more urbanized than most other countries in the sub-region. Furthermore, the pressures of drought, war and political instability, coupled with deteriorating economic conditions are rapidly increasing this pattern. Although data on internal migration are virtually nonexistent, rural to urban flows have become a recognized phenomenon in Chad, with large movements of people occurring from rural areas to urban centers both for economic as well as security reasons. The population of N'Djamena has increased five-fold during the period from 1960 to 1990 to reach nearly half a million inhabitants; and the percentage of the urban population countrywide is over 30%, one of the highest in the Sahel. While this urbanization trend might have a positive impact on the population's attitudes with regard to smaller size families due to the expected break with traditional behavior which usually occurs when people migrate to the cities, its impact on lowering fertility rates would remain minimal in the foreseeable future given the universality of marriage, polygamy, and low literacy among women. -7- Aaudy od gfids' educedmi~ carded out in 19S9 evealed that girls* acces to educationa is infidor to that of be ,withgirs reriseing34.9% of .arthnenwt in~ Grd 1 and 7%*in Grade 6. T~his same study identidiealb following goolodulttral. actors as obstacles to girls' education: household work, early namig, ,-inaplationeadlical materials to thesocIocultral m 'ille d of traditional communities, and parental pieferend in fver oednaing sons riber than d htets. . 1 tus af shieer"numrs,.womentid girlsBtepresent more.than half of the active population in Chad. By Wtuiof this fact, girls' eduWation thmgh knowledge acquired in school will help them to contribute more offelyto the country's socioconomic development;, protect the enviropment; reduce the population - grWth'rate, 6a well.as Maternal ideld mortality rates th :Mugh impived hygicepractici aid general. he education; better. edu:ate their children; and, in turn, send their children to school. Por these reasOns atla easis o girls education lsedsential . .-.. ~~~~~~~~kWdk Mtker .1d4wui,,~4~a& ~~ aea,LMl June IM9 . . 2.04 Although very high by world standards, the current estimate of the total fertility rate (TFR) in Chad of 5.9 live births per woman is among the lowest in the region which has an average TFR of 6.6. There is a seemingly high prevalence of sexually transmitted diseases (STDs) and sterility in Chad which might explain the country's lower fertility status. It is expected, however, that improved health and socioeconomic conditions and the resulting decline in mortality would positively affect fertility which is estimated to continue to grow and to reach 6.6 by the year 2000. Crude birth rates have remained constant at 45 per thousand since 1965, while crude death rates have decreased from a high of 28 to 19 per thousand. Life expectancy at birth has improved for both sexes but is still one of the lowest in the region. It is currently estimated to be 43.9 years for men and 47.1 for women. Chad is also characterized by extremely high maternal, child and infant mortality rates. Infant mortality rates which approximate 127 per thousand live births and maternal deaths estimated at above 700 per 100,000 live births are among the highest in the world. B. Implicatonsofpulaon_Growth 2.05 Three sets of population projections have been selected to illustrate the implications and consequences of Chad's rapid population growth. The first set assumes a constant fertility rate, while the second and third sets assume scenarios of gradual and rapid fertility decline, respectively. For all three projections, mortality was assumed to continue to decline at the current rate. Tables 1-4 and II-5 below show the results of this illustrative set of projections. Under the three scenarios, Chad's population continues to increase. Although it would not bring about a major significant change in the total population during this decade, a gradual decrease in fertility under the standard variant is reasonably achievable and could reduce the population growth rate toward the end of the next decade. In addition to the positive impact it would have on the health of mothers and children, declining fertility would also have a significant impact on the age structure of the population and, subsequently, on the dependency burden as the proportion of the population under age 15 is reduced. Although the country has a large reserve of agricultural land and good potential for increased production, Its economy is, nevertheless, constrained by a narrow resource base, a low level of development, and unpredictable climatic conditions. In addition, Chad has suffered severely from military conflicts, drought, and a slump in the world market price for cotton, its major export product. Per capita income declined over the period 1965-87, and even if economic recovery were to occur, it would be very difficult to match the current population growth with higher GDP growth. Continued rapid population growth at the current level would further exacerbate these constraints and would constitute a serious impediment to the country's socioeconomic -8- development. Therefore. a slowing down of the population growth rate and the establishment of a comorehensive national family planning program within the framework of a clear population goliey should be regarded as essential elements of the country's long-term development strategy. C. pulation ley, niutn and Pogam 1. POpulton Poll 2.06 Chad has no clearly articulated population policy, and the very restrictive 1965 law which prohibits the Importation, distribution and use of contraceptives has yet to be abrogated. Until recently, population growth was not seen by the Government as a major issue in development mainly because of the size of the country, one of the largest in Africa, and the low population density level. This attitude is, however, rapidly changing in the face of deteriorating socioeconomic conditions. The Government recently agreed to introduce measures to liberalize the current legislation on family planning and has officially recognized its importance for the health of women and children. The announcement of an ordinance, in November 1991, on the practice of contraception constitutes a major policy effort by the GOC and demonstrates its determination and commitment to addressing the population issue. The ordinance authorizes the use of modem contraceptive methods by the population, the delivery of contraceptive services by medical and para-medical personnel, and the promotion of contraceptive information and education, including the use of the mass media for this purpose. Another important element of the ordinance relates to the importation and distribution of barrier contraceptive products (condoms and spermicides) which had been restricted to the pharmaceutical sector. The ordinance proposes to lift this monopoly and authorize distribution by commercial outlets. The adoption of this ordinance and the attendant decree abrogating the 1965 law is presently on the Governments agenda and is expected to be enacted shortly. In the medium-term, the Governments objective is to develop and enact a population policy, and to initiate legislative reform of the current laws on marriage, polygamy, and the family code. The Government has also authorized the reinstatement of a family welfare association to be affiliated with the International Planned Parenthood Federation. This NGO will complement public sector efforts for the promotion and delivery of family planning services and will help to establish a constituency In favor of family planning. In collaboration with UNFPA and USAID the Government also proposes conducting a national seminar as a first step in the development of a population program strategy and action plan. In the first phase, the results from this seminar would be incorporated in the National Health Plan currently under preparation. 2. Populaon Institutions 2.07 Two major government institutions have principal responsibilities for population activities: the MOPHSA which is responsible for family planning promotion and service delivery; and the Ministry of Plan and Cooperation (MOPC) which is the lead government agency for overall population policy, program development and coordination. Within the MOPC, the absence of a unit to coordinate population related activities constitutes a major constraint to the development of a national population program. The Direction de la Statistique et des Etudes Economiques et Dimographiques (DSEED) has the primary responsibility for demographic research and analysis. However, its capacity for population policy analysis, research and coordination is very limited, and it has neither the staff nor the stature required to address population issues. The Government recognizes the limitations of the current institutional framework for population policy formulation and program development and intends to establish an interministerial commission to provide leadership and guidance on population matters, and to create in the MOPC a population unit to assist in the development of a population policy. With regard to family planning, activities are coordinated under the Maternal and Child Healthlamily Planning -9- (MCHIFP) program of the MOHSA. Although services are integrated at the clinical level, there is very little coordination between the program and other technical departments of the Ministry. Responsibilities are not clearly delineated and often result in conflicting situations at the service delivery level. Except for occasional events, population activities under other sectoral ministries and government agencies are minimal, and their potential, particularly in the field of IEC, remains largely unexploited. 3. The Family Plannin (FP Program 2.08 After nearly ten years of existence, Chad's FP program is still at the inception stage. While this could be attributed to the absence of a strong political commitment and the unwillingness of past governments to tackle the population issues facing the country, the civil strife from which the country has suffered during the past decade has been a major contributor in preventing the program from becoming fully operational. Activities have been constantly deferred, and the program has neither succeeded in building up an adequate technical competence nor in generating the required financial resources for its growth. More recently, a core group of trained specialists in population and FP has been established and a framework for the development of a PP delivery system in the capital city created. The program has three basic objectives, namely to: (a) contribute to a reduction in maternal and child mortality; (b) fully integrate family planning into MCH services; and (c) increase contraceptive prevalence. In order to achieve these objectives the program seeks to consolidate and expand FP promotion and services, and step up its training activities for health and social work personnel. 4. Knowledfte. Attitude and Practice of Family Planning 2.09 Information on knowledge, attitude and practice of PP and population is scarce. However, data collected in 1988 under two small qualitative surveys as well as a quantitative study of clients of health and MCH centers in N'Djamena, provide some useful insights on public opinion regarding family size and birth spacing. The analysis of these surveys indicates a low level of knowledge concerning modern contraceptive methods but a general interest in knowing more about them. Post- partum abstinence, breast-feeding, and use of a variety of traditional methods of contraception have been historically common practices in Chad, (this could, in part, explain the interest in modern contraception). It was found that women are overall better informed than men, and 60% of those who participated in the survey knew about ai least one method of contraception, while 30% were practicing birth control. Chadian men, who constitute the most resistant group to PP and birth limitation, have a strong preference for large families and fear that modern contraception will erode their traditional authority in the household. Political leaders and decisionmakers endorse birth spacing and the use of contraception as a means of protecting the health of women and children. It is among the health workers and those women who have lost infants that the positive correlation between repeated pregnancies at short intervals and poor health and high mortality is best understood. Women who attend MCH/FP clinics are usually young and in a stable partnership. They are mostly Muslim, and the majority want to use a method of contraception to space pregnancies, although they continue to state between six and seven children as their desired family size. Child spacing of twenty-six months is, in general, acceptable to a majority of women. Sources of information on modern contraceptive methods are very limited. The MOPHSA Health Education Unit has no capacity for the development of family planning IEC strategies and programs, largely due to the fact that IEC activities in Chad have always been project related, with each project individually responsible for its own message development and dissemination. The very modest PP communication programs that exist rely primarily on face- to-face communication with women who visit the health centers, and very little use is made of the mass media to educate and inform the population on family health matters and to promote individual responsibility for FP. Unless an effective and well-coordinated IEC program is pursued, it is highly unlikely that the current pronatalistic attitude of the population in general and the strong resistance of men to PP will be seriously tackled. - 10- D. Fami Plannng Servim 2.10 Service Deliy. FP services are gradually being introduced in public health centers as an integral part of the MCH program. In 1991, there were reportedly eight public health facilities providing contraceptive services, including a National Family Health Center recently established in N'Djamena, under a UNFPA project. All of these facilities are located in urban areas and thus most of the rural population remains unserved. The National Family Health Center functions as a reference clinic and is also used as a training site for medical and para-medical personnel. The center provides MCH/FP services, prenatal and postnatal care, as well as counseling and treatment of sub-fecund and sterile women. Although the Government has indicated that FP services have now been extended to three other major urban centers - Moundou, Ab6ch6 and Sarh - it is too early to evaluate the importance or impact of services offered there. In the absence of reliable service statistics, current assessments of FP service utilization are based on quantities of contraceptives distributed in the country and the number of recorded family planning visits in clinics. This information suggests a modern contraceptive prevalence of less than 2% among all women of reproductive age. Oral contraceptives, condoms and small quantities of injectables are available in the health posts, and clinical methods such as the intrauterine devices and tubal ligations are administered only at the national reference center and the main maternity center in N'Djamena. Oral contraceptives are the method most preferred by women; and injectables and intrauterine devices rank, respectively, second and third. Use of condoms and other barrier methods is insignificant. Unmet demand for PP is thought to be considerable. The very high number of abortion complications seen in the health facilities is indicative of the latent demand for contraceptive services and is becoming a matter of concern in public opinion and among health professionals. 2.11 Communication Programs. Current IEC activities consist primarily of the dissemination of basic messages intended to improve awareness and knowledge of modern contraceptive methods among adult women who visit FP clinics, and very little is being done to influence behavioral change in favor of smaller family norms among other segments of the population. Message content is generic and solely emphasizes the benefit of birth spacing on the health of women and children. The main communication channel is either interpersonal or group discussions conducted primarily by health personnel with little or no training in communication techniques. Use of qualitative research to gain insights on the information and education needs of specific population groups such as men and young adults remains extremely limited, rendering the production of more focused messages and the development of a multi- media approach to IEC very difficult. There is a dearth of audiovisual and print material, and whatever is available has been produced elsewhere in the region. Production capacity, with probably the exception of Radio Tchad, is almost nonexistent and would require sustained long-term support to become fully operational. In addition, the MOPHSA's institutional capacity to design and implement a research-based IEC program needs to be strengthened. 2.12 Private sector participation. The private medical sector is very limited in Chad with only a few practicing physicians operating in N'Djamena. The sector plays a minor role in the delivery of health and FP services and its prospects for expansion are minimal. However, the pharmaceutical sector has more potential and could be developed to play a significant part in the distribution of contraceptives, and enhance and complement the public sector program as a major source of resupply at least in the urban areas. Contraceptives are available in the four private pharmacies in N'Djamena and to a lesser extent in the network of twenty-four pharmaceutical depots throughout the country. PHARMAT, a semi-private firm, is the principal importer and distributor of contraceptives in Chad. Its records show an average annual import of 24 thousand cycles of oral contraceptives and 2,000 doses of injectables. However, imports are made on an ad hoc basis with the consequent disruption in supplies. In addition, sale prices to the public are very high and thus discourage the low-income population from seeking pharmacies as a source of contraceptive supply. The Government has agreed to reactivate the Association Tchadlenne - 11 - de Blen-Etre Famlial (ATBEF) and has approved its statute. The ATBEF will sensitize government officials, national planners and decisionmakers on population issues and participate in the promotion and delivery of PP services. There Is also a large number of NGOs collaborating with the Government In the health sector and while none of them have ventured into the provision of PP services, they could be encouraged to participate if an appropriate environment were created to organize and coordinate their input. Toward this end, the current Government efforts to foster collaboration between the public and private sectors should be further supported and acknowledged as a major element of future national population strategies. 2.13 O ' Ass . Donor support to Chad's population program was initiated in the late 1970s with small-scale interventions focused mainly on building up a constituency in favor of the introduction of FP and the development of a national population policy. Due to war and civil strife, assistance was provided on an ad hoc basis until 1986, when the country returned to a condition of relative stability. Donors' financial contribution to population activities constituted less than US$1 million during the period 1986-87. USAID and UNFPA have been the most active donors with technical and financial support for policy and human resources development, and the provision of family planning information and services in the city of N'Djamena and the surrounding areas. Both donors have recently stepped up their efforts to help the Government develop and implement a comprehensive MCH program with integrated FP services. The amount of UNPPA funded activities for the period 1989/93 would total US$3.5 million and USAID, under its Child Survival Project would provide up to US$8.5 million over the next five years. UNFPA activities concentrate primarily on the provision of technical and financial assistance for the execution of a population census, population policy formulation, and the consolidation of MCH/FP program management at the central level. Given the significant volume of external assistance in policy development and health planning and management provided at the central level by other donors, USAID has decided to shift the emphasis of its project resources to the prefecture level, where it aims to strengthen MCH/FP service delivery and develop a capacity for health planning and administration. The project would be implemented in the three adjacent prefectures of Salamat, Moyen Chari and Logone Oriental. USAID will continue, however, to provide support to the Statistics Division (BSPE) at the central level to strengthen its capacity for data collection and analysis, improve the health information system, and incorporate MCH/FP data into the system. . 12- M*I. EALTHi A. Health Status 3.01 Only about 30% of the population residing in the Northern regions and about 45% of the population living in the Southern regions of Chad have access to health services, including private and church-affiliated services." Therefore, although the quality of the data Is good and the percentage of facilities providing health information reports is high (about 85%), the representativeness of the information provided is curtailed by the limited access to health services. Moreover, the type of information collected does not follow the International Classification of Diseases and reflects, to a large extent, the capacity of health personnel to make an accurate diagnosis. There is, for example, no accurate information on the number of cases of malaria because blood testing is not available to confirm suspected cases. The available data suggest that the health situation in the country is very precarious, the principal causes of mortality and morbidity being infectious and parasitic diseases (including most of the common tropical diseases), pregnancy-related conditions, and malnutrition. Reports from the new Information system at the MOPHSA (para 3.41) indicate that health problems in 1991 remain the same as those of previous years. Fever, usually an indication of infectious or parasitic disease (usually considered to be malaria by Chadian health workers), cough, muscular and articular pains, traumas, and diarrhea continue to be the principal reasons for consultations in health facilities. Table II-1: Princlal Reasons for Consultations in Health Facilities by Year (in%) 1988 1989 1990 1991 Fever 11.8 11.6 11.9 12.6 Cough of less than 15 days 9.9 10.3 10.6 10.9 Traumas 9.0 9.0 7.8 7.4 Muscular/articular pains 8.5 9.5 9.5 9.3 Diarrhea 8.5 7.8 8.0 8.1 3.02 As expected, the prevalence of specific types of health problems varies with age, with acute respiratory infections, fever and diarrhea being most prevalent among children 0-4 years old (a total of 51% of disease episodes). Together, diarrhea and dysentery represent 20.5% of consultations for children under 1 year of age and 19% for children between 1 and 5 years of age. In addition, infants under 5 years of age suffer from conjunctivitis, skin infections and otitis. For the rest of the population, muscular/articular pains and headaches are the most common reasons for consultation (12.9%) followed 4 Unless otherwise indicated, the source of data used in this report is the 1991 Annuare de Stastiques Sanitaires du Tchad, MOPHSA, Tchad, as well as the 1992 unpublished edition. - 13 - by fever (10.6%) and traumas (8.6%), with diarrhea and dysentery representing 8.1% of the total disease episodes (Annex W.1 - Fg.1). 3.03 SeasnanlgWb1cal YadtiQ. To a large extent, seasons influence the general health conditions of the population: the "weakening" of individuals during the period preceding the next harvest is a common phenomenon in Chad as in most Sahellan countries. In addition, cyclical famines occur during periods of drought. The Incidence of certain health problems varies largely with the season of the year: outbreaks of meningitis, conjunctivitis, otitis media, sore throat, and diarrhea occur priaarily during the dry season, while fever, cough and tetanus are more frequently reported during the rainy season. For example, the number of cases of meningitis, a common problem in the Sahel, starts increasing in January to reach a peak in March-April while cases of fever start increasing in June, reach a peak during the rainy season, and start decreasing in October. Cases of neonatal tetanus are most frequently diagnosed in August (An M.I - Fig.2). 3.04 Certain health problems seem to be more prevalent in some parts of the country than in others. For example, residents of the South seem to be more exposed to onchocerclasis (147,000 estimated cases of which 20,000 with blindness) as well as trypanosomiasis, while those of the Sudanese region seem to be more vulnerable to malaria. On the other hand, waterborne diseases such as bilharzia are more prevalent in the lake region. 3.05 Wt and sanitation.3 A large number of the health conditions can be attributed to the lack of access to safe water and poor sanitary conditions. It is estimated that only about 43% of the urban and 23% of the rural population have access to safe water.6 The situation in the sanitation sector is even worse. There are no sanitation and garbage collection systems, resulting in enormous health hazards. IDA and other donors are taking measures through specific projects to improve public hygiene and living conditions. However, the needs are enormous and the projects' impacts are relatively minimal. 3.06 Sol environment. Some health conditions may be attributed to the social environment in the country. One example is alcoholism which is increasingly believed to be a cause of mortality and morbidity in Chad.7 The problem of the handicapped In Chad is not so much a consequence of diseases (poliomyelitis, meningitis, leprosy, unattended traumas and accidents), as of war-related injuries. The exact size of the handicapped population in Chad is not known. However, 1990 estimates indicate that there are about 487,000 people with some form of physical handicap in Chad (about 10% of the population).$ An examination of the various sources of information indicate wide variations in estimating their number per catego*y of handicap and severity. This diversity is due mainly to the different evaluation methodology, and the lack of precision In the definition of a disability. s This subject is not treated in detail in this report. For further information, see World Bank Report, , August 1990. 6 World Bank, Social Indicators of Development. 1991-1992. 7 Bouquet, Christian. Thad.* Gense d'an Co4lit, 1982. S MSP/MPC, 1992. Docmnent de traval. Sfninatre prdparatolre Santd/Affalres Sociales, Table Ronde, page 35. -14- B. SpealcHealth.Problemns 3.07 DIWhe is common throughout the country with 8.1% of the population having reported the problem during an outpatient visit in 1991. As mentioned earlier, it is a major cause of childhood morbidity and mortality. The number of dehydration cases reported in referral centers in 1991 was about 5.5% of total new cases. As mentioned, the incidence of diarrhea cases and dehydration is higher among the younger age groups (18.1% and 7.5%, respectively, for children under 1 year of age; 14.1% and 6.9% for children between 1 and 4 years of age; and 4.6% and 2.6% for the rest of the population). The specific causes cannot be identified but the majority are believed to be caused by the wide variety of viruses and rotaviruses. 3.08 Nutrition-atd conditions. Malnutrition is dealt with in greater detail in Section IV of this report. About 3,040 cases of kwashlorkor were reported in 1991 (0.16% of new visits), representing an increase of 42% from the previous year with the majority of cases among the 1-4 year age group. This sharp increase could be explained by better reporting, the measles epidemic, and variations in food availability. Kanem and Logone Oriental, followed by BET and Mayo-Kebi are the most affected regions. 3.09 Data on the extent of malnutrition cited in various reports are alarming. For example, the Central Hospital in N'Djamena reported that about half of the children hospitalized during 1990 suffered from malnutrition and that almost 30% of them died in the hospital. Malnutrition rates obtained from nutrition surveys show large seasonal variations ranging from 4.4% in February to 40.6% in April in one particular region (Biltine). 3.10 'Iberculosis. About 19.5% of outpatients who complained of chronic cough were diagnosed with tuberculosis in 1991. A total of 2,826 new cases were diagnosed in the same year (a 10% increase with respect to 1990). A survey conducted in 1989 in Ouaddai and Mayo-Kebi shows that only 30% of the patients completed the treatment and were completely cured. The tuberculosis program is currently active in three out of 14 prefectures and is expected to be extended to the rest of the country. 3.11 Malara. The cases of malaria are included under fever in the health information classification system used in Chad. All persons with fever greater than 38.5 degrees centigrade (98.6* F) are assumed to have malaria and are treated with chloroquine. A survey conducted by Mddecins Sans FronIres personnel in 13 sentinel posts in the North of the country revealed that the rate of confirmed cases of malaria among patients with fever over 38.5 degrees centigrade ranged between 2% and 60%. At least 20% of the cases were confirmed as having malaria when the fever occurred during the rainy season, while only 5% of the cases were confirmed as malaria cases during the rest of the year.9 Activities planned by the national malaria program focus rightly on integration within primary health care services. The five-year plan' describes the whole range of curative, preventive, and research activities while indicating the decision-making and responsibility levels (central, intermediate, and periphery). Although well-designed, this program has yet to become operational. 3.12 rypano smlai. Trypanosoma brucel gambiese is endemic in the South of the country. Results of surveys suggest that there are at least 27,100 persons at risk, with 134 new cases having been reported in 1991. The trypanosomiasis program has been inactive for several years and a new program, " MSP/CHEMA/SCET-Tunisia. 1989 Etude du Secteur de la Sant, Volume 3, page 13. 10 MSPAS, Pl de L=e A allud a had 1991-1995, Chad. - 15 - launched in May 1990, Is not yet fuly active. While 98 new cases were identified through this new program between January and May 1992, anti-vector campaigns are not expected to start before 1993. 3.13 Draunculosis. Health personnel report seeing fewer cases over the years. Only 40 cases were diagnosed in the sentinel centers between 1988 and 1991, mostly in the southern part of country, near Moundou and in the east Salamat province. The actual prevalence of this disease is unknown but a survey is envisaged in 1993 in collaboration with WHO, UNICEF, and the Centers for Disease Control. 3.14 Qnhoceriasis. This disease is concentrated in the southwest of Chad particularly in the Logone Occidental, Mayo-Kebi, Logone Oriental, Moyen Chari, and Tandjile. A total of 750,000 persons live in the endemic area, 147,000 of whom are infected by the onchocerca volvulus, and 20,000 are blind as a result of the infection." This disease has an important economic Impact because it forces people out of areas that have good agricultural potential. 3.15 Lg . As of the end of 1990, a total of 8,433 cases were reported in Chad (i.e., a prevalence rate of 1.6 per 1,000), 255 of which had been newly detected in 1990 (five cases per 100,000). This disease is believed to be underreported in Chad as the population does not perceive that the treatment is effective and, therefore, does not seek care in the health facilities. To correct this situation, the new leprosy program is decentralizing treatment and trying to reach infected patients through the local health facility. Also, the traditional Dapsone treatment is being substituted by a multichemotherapy regimen. 3.16 Bilharasis. Intestinal and urinary forms of bilharziasis are present in the country. The endemic area (more than 200 cases per 100,000 persons) covers Mayo Kebbi, Logone Occidental, Chari- Baguirmi, Tandjile, and Ouaddal. Generally, symptoms of this disease are not perceived to be alarming therefore resulting in its underreporting. Preliminary findings of a survey conducted in the Southwest of the country suggest that 80% of the school children were afflicted with the disease. 3.17 Meingitis. Epidemics of meningitis occur across the Sahelian belt. The number of cases of meningitis registered in Chad during 1990 (6,189 excluding N'Djamena Central Hospital) reached an alarming level particularly in the five Southern provinces (92.5% of the cases). A sharp decrease was, however, noted in 1991 when 885 cases were diagnosed, Tandjile and Moyen-Chari being the most affected areas. 3.18 Cholea. The cholera epidemic of 1991 affected all the prefectures in the country except Salamat, and only one case was found in the Moyen-Chari. The total number of cases was 13,915 and 1,344 deaths were reported (mortality rate about 10%). While the largest concentration of cases was reported in N'Djamena (9.4 cases/1,000 people), the mortality rate was highest in BET (27%), followed by Lac (26.6%), Kanem (23.7%) and Batha (23.6%). The epidemic that started in May was completely under control by the end of November. 3.19 Measles represents a significant threat, particularly to nutritionally debilitated populations. While efforts have been made to carry out mass immunizations, the incidence of measles remains high. In 1991, 21,182 cases were reported, which represents almost a 300% increase from the numbers cited in 1989 and 1990 (7,449 and 7,226 cases, respectively). The fact that about 9% of cases in 1990 were reported to have been previously vaccinated is of special concern, raising questions as to the efficacy of the vaccine distribution and storage system. n Ibid. - 16- 3.20 Seual traM diseases (M knluding AIDS. The total fertility rate in Chad in 1990 was about 5.9, well below the average 6.6 for the Sahelian countries. While It is suspected that this Is due to the prevalence of STDs, the unavailability of statistics makes it difficult to substantiate this fact. The only Information available dates from a preliminary analysis of 1985 data from 32 MOPHSA facilities (excluding hospitals) that provided curative care which reported gonorrhea as one of the major diseases in Chad (3% of visits in 1985).12 3.21 Since 1987, AIDS has preoccupied officials in Chad. The scale and urgency of the problem are growing rapidly and are possibly grossly underestimated. In November 1985, a survey was carried out in N'Djamena which found one out of 331 persons tested to be HIV positive, indicating the presence of the virus in Chad. During the period 1986-1989, 21 cases of AIDS were reported to WHO.13 As the AIDS diagnostic and surveillance systems improved, this figure increased to 224 cases as of December 1991.14 The number of cases has practically doubled each year from 1986 to 1991 indicating an increasing threat of an epidemic (Anne 11.2). The median age of patients is 24 years. Of the 38 cases reported in 1990, 24 came from the N'Djamena Central Hospital, and from the Medical Centers of L6rd, Moundou and Sarh. It is highly likely that the true number of cases is seriously underestimated since some AIDS patients do not necessarily seek treatment, the ELISA serological test to confirm diagnosis is not widely available, and the reporting system in Chad is unreliable. According to a survey of major cities undertaken by the MOPH in 1989, the rate of HIV infection is 1.6%, 0.5%, and 0.2% in Moundou, Sarh, and N'Djamena, respectively. Clearly, the actual reported AIDS cases represent the tip of the iceberg. An intermediate-range plan was developed in 1988 with the help of WHO. The strategies followed focus on: (i) epidemic surveillance; (ii) blood banks; (iii) IEC activities; and (iv) mobilization of women. The AIDS program gathers data from six sentinel posts where all pregnant women, blood donors and TB patients are screened.0 The AIDS program suffers from an overall poor community awareness of the seriousness of the problem, poor skills among personnel, and a shortage of resources (particularly supplies for blood tests); the program's effectiveness is also hampered by logistical constraints with respect to follow-up and field supervision. 3.22 P=ano-Wated problems. Maternal mortality in Chad is one of the highest in the world. In the N'Djamena Central Hospital, the rate of maternal deaths per 100,000 live births was 833 in 1986, 747 in 1987, 927 in 1988, and 710 in 1989, an average of 811 for these four years However, this rate decreased dramatically in 1990 and 1991, with 433 and 197 deaths per 100,000, respectively. The drop in maternal mortality can be explained by the improved quality of health services in the hospital as a result of the interventions by the French Cooperation. However, these are hospital n Health Policy Institute, April 1986. A Preliminary Sector Review with Terms of Reference for a Preinvestment Study and Institutional Reinforcement. Submitted to the African Development Bank, Abidjan, C6te d'Ivoire. 0 MSPAS, Progranme National de Lutte contre le SIDA. Rapport Annuel 1991; Plan de 7)avail 1992. 14 It is worth mentioning that of the 224 declared cases, 165 were identified in 1991. I The rate of AIDS infection among these target groups range from 0-4% for pregnant women, 3-11% for TB patients, and 0-3% for blood donors. 16 UNICEF and Government of Chr4, August 1990. Une Analyse de la Situation des Femmes et E4fants du TMhad (draft document). - 17 - rates and do not reflect the real situation In the country (a rate as high as 1,000 per 100,000 was reported in some rural areas of the South).1 The average rate for Africa is estimated at 640, and for North America and Europe at 20. 3.23 A study of N'Djamena Central Hospital revealed several causes of maternal mortality. Among the direct causes, hemorrhage/anemia leads with 29% of maternal deaths, followed by eclampsia (18%), and post-partum and post-abortum infections (13% each). Many indirect causes contribute to maternal mortality: early marriage, lack of child spacing, clandestine abortions, difficult access to prenatal health services, lack of hygiene, ignorance, etc. In 1987, the N'Djamena Central Hospital reported that 17% of the 969 women hospitalized there after abortions died."6 Female circumcision, an African tradition that is believed to be a major contributor to pregnancy-related complications and deaths, is widely practiced in Chad. It is estimated that about one-third of the female population is affected, particularly in the regions bordering Sudan." No official data exist on this issue, and there is general resistance among Government officials and health personnel to discuss it. 3.24 Recent statistics show that women are increasingly utilizing the health system: the number of women attending prenatal care clinics increased by 5.5% in 1991. While there are regional variations due to different cultures and access to health facilities, the number of institutional deliveries has sharply increased nationwide. C. Health Poly and Health Planning 3.25 The GOC subscribes to WHO's primary health care strategy and goals as a means to extend basic health services to the population. In a Government policy statement presented to an international conference in Geneva in 1985, the official emphasis for the human resources sector in Chad was on "strengthening existing human and technical resources rather than creating new structures:...in the field of health it means improving health conditions for the greatest number at the lowest cost, placing special emphasis on preventive actions and mass medicine."2 A similar strategy based on providing primary health care services to the largest number of people was elaborated in a more recent Government Development Plan.21 Under this plan priority is given to: (i) education and prevention activities as well as strengthening basic curative services; (ii) establishment and operation of a health system based on health districts; and (iii) deconcentration and decentralization of decision-making to the regional level. 17 Ouadjou, Ouarmaye and Morch, 1988. Enqute sur la Mortaltd Maternelle et le Fonctionnement des Consultations Prinatales dans le moyen-Garl. n Ministry of Health, 1988. Confdrence sur le Blen-0tre Familial au Tchad. Final Report. 19 UNICEF, 1989. Rapport de Vnthse sur les Recherches et Enqu&es Relatives aux Pratiques Traditionnelles ayant des Effets Nifastes sur la Santi des Femmes et Eqfants as Tchad. 21 Ministre du Plan et de la Reconstucdon Nationale. 1985. Gouvernement du Tchad. International Conference for the Economic Development of Chad. Vol.I: The Development Program. 21 Mnlisa&re du Plan et de la Coopdration, R6publique du Tchad. Plan d'Orientation: Le Thad vers I'An 2000. -18- The policy statements have emphasized the aim to ensure widespread availability of services, especially for the most vulnerable groups. 3.26 The health sector in Chad relies heavily on donors for financing. More than 80% of national health expenditures (both investment and operating) are provided by donors. Until recently, program planning in the MOPH was carried out primarily in terms of development of specific projects to be proposed for multilateral or bilateral donor funding. There was no health plan other than the list of projects that had been approved by the Ministry of Plan for inclusion in the Government's 1986-1988 Interim Development Plan. Planning - whether for the parts of the health service delivery system funded by the Government or by donors - was severely hampered by the lack of basic, reliable data on existing facilities, manpower, health status, and population. 3.27 Faced with the impossibility of providing widespread coverage, the Government is pursing an aggressive cost recovery policy. Currently, there is an official policy of charging for outpatient visits for services provided by the MOPHSA. Hospital inpatient services are officially free, and students, civil servants and military personnel are exempted from the consultation fee. Like all countries who have subscribed to the Bamako Initiative, the Government has created a committee responsible for studying and adapting cost recovery to the country's specific situation, and is in the process of redefining its fee policy. Essentially, the question to be addressed is: "What health care costs should be covered by community participation"? With the assistance of donors, the Government is revising its fee policy for services and medicines, as well as the use of revenues from fees in the public sector. 3.28 In spite of announced commitments to a primary health care approach, the sector has been dominated, until recently, by vertically oriented programs some of which, such as the Expanded Program for Immunization, have received major multiple donor support (para 3.56). Civil disturbances and economic problems over the last decade greatly hindered efforts to implement PHC in many ways, including loss or degradation and inaccessibility of infrastructure, disappearance of non-salary operational budgets, complete dependence upon external financing, and the constant need to focus on severe immediate problems at the expense of a longer-term perspective. Vertical programs in Chad were not only designed but also implemented from the central level, thus disrupting all primary health care activities planned by the provincial or district levels. Recently, efforts have been made to integrate all activities of the vertical programs into the packet of activities to be executed at the provincial or district levels. 3.29 The GOC, with the support of major donors, has taken steps in recent years, to strengthen health services planning and management, to coordinate interventions in the sector, and to develop plans aimed at increasing coverage by appropriate basic health services. The overall process being followed and the organizational and functional frameworks which are to be established are described concisely in the April 1991 report of the AfDB-financed project.2 This process includes: (i) a series of seminars to discuss the proposed health reforms with health personnel, particularly the district and regional medical officers; (ii) the preparation of a plan for the restructuring of health districts (Plan de Couverture Sanitaire); and (iii) a new model for the organization and functioning of the MOPHSA based on a three- 2 Arrtd Ministdriel du 25 fvrler 1989 portant crdation dwu "comitd de conception d'un systfme de recouvrement des cots de la santd au Tchad". 23 PERI, Avril 1991. Ministgre de la Santg Publique, Ripublique du Tchad. Projet Etudes et Renforcements Institutionnels. MSPAS/BAD/CHEMA/SCET: Ralisation et Perspectives. - 19 - tiered decentralized and deconcentrated system, the integration of activities and programs, and a participative action- and result-oriented management approach (Annex 1.3). 3.30 As a result, very good progress has been made in health services planning and management, particularly the publication of the interministerial bylaw (No. 102, 10/26/90) instituting the system of cost recovery; the creation (by fusion of two Ministries) of tht Minitry of Public Health and Social Affairs (MOPHSA); the improved organization of MOPHSA mandated in Presidential Decree No. 5191PR/91; the nearly completed plan for restructuring health districts; and the establishment of a health services management information system. Most recently, following simultaneous IDA and WHO missions to Chad in December 1991, the GOC agreed to the reinstatement of the long-term technial assistance which was provided under the AfDB-flnanced PERI in order to revitalize the Groupe National in charge of preparing the Round Table. Technical support is being provided to: (i) implement the mandated MOPHSA reorganization; and (ii) produce a National Health Development Plan, including definition of priorities, strategies and approaches, development of staffing and service standards, resources needed, and a timetable for implementation. As a first step in the process of preparing the National Health Development Plan and the Round Table, a Sdminaire de Concertation National was held in June 1992 with the purpose of presenting the broad outline of the National Health Development Plan; a document outlining the broad lines of this plan was discussed. D. Institutional Context 1. Structure of the MOPHSA 3.31 The capacity of the central level of MOPHSA is generally very weak,' and the personnel morale very low. Like in many SSA countries, salaries of health workers have fallen drastically; their skills have greatly deteriorated and adequate opportunities for in-service training are practically absent. Moreover, adequate protocols and standards of treatment are unavailable. 3.32 Plans for the reorganization of the MOPHSA were developed with the support of the AfDB-financed PERI and were based on the integration of the Ministry of Public Health (MOPH) and the Ministry of Social Affairs and Women's Development (MSAWD), and the coordination of their staff as well as their activities. While the newly mandated organization has been officially approved, its implementation awaits the nomination of persons to key positions particularly the directors (Annm I.I4 for MOPHSA's new organizational structure). Meanwhile, the MOPHSA functions along the old organizational lines with rigid partitioning between the directorates and a nearly total lack of coordination between health and social affairs. As a result, it suffers from almost total inertia with personnel uncertain of their role and reporting responsibilities. Given the important role that the central level must play in this new reorganization, especially in supervision, control and providing assistance to intermediate levels, this situation is particularly serious and urgently needs to be resolved. 3.33 PERI has achieved, among other things, the definition and typology of a greatly improved health care system for Chad. This system is essentially three-tiered (central, intermediate and peripheral) with the three levels linked by an administrative system that is deconcentrated (regions and districts) and decentralized (hospitals). Emphasis has been placed on technical needs and the creation of a management structure with a comprehensive view of the health field. The referral health care system 4 There appears to be a common opinion among donors that the administration of the MOPHSA functions very badly and that it is worse than the administration of other Ministries in Chad. -20- is such that each health facility provides a minimum package of activities, the complexity of which increases the higher the level of service delivery. 3.34 In order to apply the new concept of the health system, a health redistricting n (Plan de Couverure Snkaire) is being finalized. The first phase of the plan, which consists of defining the health districts, is almost complete: the health region (pr#fecture sanitaire) remains the functional administrative unit. Using geographic and demographic criteria, each region is divided into smaller functional units - the health districts. Each district is expected to cover a population of 100,000 to 250,000 people and will include a medical referral center responsible for the follow-up of district health posts which, in turn, have a well-defined responsibility zone (population of about 10,000). At each level of the pyramid, a minimum package of equipment, personnel, as well as a minimum package of activities have been defined and are being finalized. In this process of restructuring, a series of seminars have been conducted for key actors particularly for district health officers. 3.35 As redefined, the role of the cntevel in the newly mandated organization of the MOPHSA is that of policymaking, health planning and control, as well as resource allocation. It does not execute health and social activities, neither centrally nor locally. There are six central directorates (direction) each of which consists of two to six divisions. In addition, the deputy directorate general (Direction Gdndrale a4joLte) oversees, supervises and coordinates all the socio-health regions (prdfectures soclo-sanitaires), and ensures proper implementation of the regional health plan. The functions of the MOPHSA directorates are shown in Annex M A. 3.36 At the intermediate level, the Regional Medical Officer (RMO) is the director of regional health services (DWidgud de prdfeeture socio-sanitaire), and is responsible for overseeing the planning, management and supervision of all health activities in the region. Each region has an administrative committee as well as a regional council for health and social affairs. In each of the 14 regions, the RMO oversees the division of planning and programming, the division of resources (human and financial), the regional hospital as well as the socio-health districts. 3.37 At the p rl level, the health district corresponds to a well-defined geographical zone containing two levels of service: the district hospital as well as several centers/health posts. The redistricting plan has divided the 14 regions into 48 health districts, each divided in turn into responsibility zones (zones de responsabild). The District Medical Officer (DMO) reports to the MOPHSA through the RMO. His responsibilities include the following: administration of the district hospital; management of human and financial resources in the district as well as health information; ensuring the supply and distribution of drugs and small equipment for the district; securing proper management of funds generated through community participation; and overseeing the proper implementation of the plan de couverture socio-sanitaire. Training of personnel is carried out at all levels, its locus being determined by the type of training (basic or continuous) and the personnel to be trained. 3.38 Throughout the various levels of the MOPHSA, coordination among divisions is ensured through administrative committees. For example, at the apex of the pyramid, the committee includes the directors of national institutions as well as the Director General. The committee within each directorate includes the director and the division chiefs. At the peripheral level, the coordination committee is composed of all chiefs of responsibility zones as well as the administrators of socio-health centers. 3.39 In addition to its central and regional organization, the MOPHSA has a number of national institutions and organizations that are placed under its aegis: the School of Public Health and Social Services (Ecole Nationale de Santi Publique et du Service Social, ENSPSS); the National Center -21- for Rehabilitation (Centre NationalddAppaielage et de Rdducation, CNAR); the National Hospital; the National Laboratory; and the Pharmacy in charge of supplying the public sector (Pharmacle dWpprovisionnement du Secteur Public, PASP). Their functions and responsibilities, as enumerated in separate decrees, are adequate and well-defined. 2. Managmentilealth_InfornaDpAbhLStatistics ftem 3.40 In recent years, the GOC has made substantial efforts towards improving health information. In October 1985, the MOPH could not report how many health facilities of what type were functioning in the country.2 Data on the activities of and diseases treated at health facilities, mandated by the various divisions, arrived erratically if at all, and in 1985, only 2% of all expected reports had arrived at the divisions or the statistics bureau. Therefore, in order to strengthen the health planning capacity of the Government, one of the first priorities of Chadian health authorities has been to strengthen its capacity for information collection and management at all levels. 3.41 At the request of the Government, USAID provided funding for technical assistance to the Statistics and Planning Unit of the MOPH to establish a viable health information system. A commission for the Health Information System was established by the Director General and included all division and program directors as well as representatives of donor agencies and of NGOs. Together with the team from the Harvard Institute for International Development they examined information needs and proposed methods for data collection and analysis. An office of Planning, Statistics and Studies (Bureau de Statistiques, Planfication et Etudes, BSPE) was created in April 1986 through funding from USAID and attached directly to the Director General in the MOPH (under the newly mandated reorganization of the MOPHSA, BSPB is located in the Directorate of Planning and Training which includes a division for planning and one for a health/social information system). As a first priority, the BSPE focused on the establishment of a computerized health Information system. A list of facilities was established for sentinel sites (Postes Sentinels, PS), primary health facilities, as well as indicators to be generated in each health facility. Based on predetermined criteria, a total of 39 PS (hospitals, health centers, and a few health posts) were selected from a list of health facilities.2 A standardized routine MIS for all health facilities in the country was developed based on a number of criteria described in Annex MI.. 3.42 In December 1989, the Projet de Restauration de la Planificaton SanitaireY financed by USAID and UNDP and executed by the MOPHSA with technical assistance from the Harvard Institute of International Development, came to an end. The 1990 statistical yearbook was therefore produced by the national team at the BSPE with financial assistance provided by the USAID through the "Child Survival" project (1989-1994). 2 Foltz, Anne Marie. October 20, 1986. Planning without resources: Health Information in Chad. Harvard Institute for International Development. 2 For a list of postes sentinels, see Annex F of Annualre Statistique, 1990, BSPE. 2 So far, four statistical yearbooks for Chad have been published covering, respectively, the period July 1987-June 1988, and the years 1988, 1989, and 1990. Two volumes of each yearbook have been published. Volume A includes national and provincial data on demography, health problems, health resources (including external assistance), and health facilities. Volume B consists of one volume per province and presents more detailed local statistics (often by health facility). -22 - 3.43 The significant work of the BSPE, particularly the development of the health information system, constitutes one key to the successful formulation of a National Development Plan. However, to improve its usefulness as a planning tool, the system needs to improve on the quality and completeness of data and to provide information on budgets, financing, as well as pharmaceuticals, especially with the institution of cost recovery. The BSPE is currently carrying out a revision of the health information system to include more management information (patient, service and overall system). For this purpose, users' workshops are being organized for central directors, persons responsible for national programs, and regional medical officers. 3. PrIvakteInstitutionsMGOs Box 3.1 . tI addition to Go)vernmen0t see, health care in Chad is also provided by a varity of private organizations .h.ind Volnty Agence. (VA) such as -ue saik charitis istralheah socs pwidedby. certain industries ad op ane ad privte serikes offerd b tdithional.haler and.birth attendants. The w also so unknown number of abinets emn hc r a heald popstt whete ~ulicSd personl provide troeatet disense drugs, and give iqection illegall.4Whil. oe ordnties amnong NGOs dos exist, prildy aong chrh groups, it i.y Sl.d o be sfficit giv.s h. t of the setor ad the role it plays i. the delive.y ofhh serie. in Chad.... 3.44 In the health sector, EfQQa provide valuable support to the MOPHSA, in particular by extending their activities at the regional level. Aside from emergency nutrition and medical relief provided by such private Voluntary Agencies (VAs) as Care, the Red Cross, and World Vision, basic health services have been provided by a variety of charities such as Mddecins sans FrontiUres (MSF) and church-sponsored organizations on a long-term basis. The church group activities are concentrated in five southern prefectures. Their facilities represent the largest share of private sector health capacity; they operate about 24% of the enumerated health facilities and provide an estimated 50% of health services in the southern areas of Chad. Although church groups have their own management, drug supply, distribution, pricing, record-keeping, and training systems, they follow national health policies dictated by the Government and are an integral part of the national health information system. For example, The Evangelical Mission Alliance (TEAM), the largest protestant group, operates a 220 bed hospital in the Tandjile region with 19 satellite rural health posts. Fees are charged for outpatient consultations and for inpatient care. Medicines are delivered by two TEAM airplanes. The SECADEV, a relief and development association of the Catholic church, is another major provider of health services. In addition to providing health care, SECADEV carries out a number of other development activities and has, as a result, been particularly successful in mobilizing the community and implementing cost recovery mechanisms in some of their health centers. 3.45 Industri in Chad (SONASUT, Coton-Tchad, Brassertes, Cyclo-Tchad, Manqfacture des cigarettes du Tchad, etc.) with support from UNDP, operate about 10% of enumerated health facilities -23 - and employ about 4% of health personnel.28 They provide health care to their employees and their families, mostly in urban centers. Information on the quality and utilization of their services is not available. Similarly, very little information exists on the nature, availability, or numbers of tradinal ealera. Although it is suspected that they play an important role in providing health care, no information exists as to the type of care provided nor to its impact on the users. In the 1970s, the MOPH initiated a program to train and integrate 10 traditional healers into the Government's health services system. This effort reportedly encountered several problems and was discontinued in 1979. It remains unclear why this effort failed and what steps could be taken to capitalize on this important sector. 3.46 Coordination of NGOs. Some efforts have been undertaken recently to establish closer ties among the church health services, and between those services and the MOPHSA. One major coordinating body in the VA sector is the UNAD (Union Nationale des Associations Diocdsaines de Dveloppement) which has one medical doctor serving as the health sector coordinator for the various dioceses. This has allowed the VAs to ensure harmony of interventions, to define the general common direction and to have one speaker vis-I-vis the MOPHSA with respect to national health policy and its application. For example, UNAD organizes the supply of drugs for all church-affiliated facilities and negotiates agreements, with the Government, with respect to the importWon of medications for these facilities. Representatives of both the Roman Catholic and Protestant groups are also members of several coordinating committees established by the MOPHSA. 3.47 At the Government level, NGO coordination is the responsibility of the Secrdtariat Permanent des ONGs (SPONG) in the Ministry of Plan and Cooperation. SPONG was created in October 1985 and given the following responsibilities" (i) enumerate all NGOs in Chad; (ii) orient their actions in such a way that they are in line with the development strategy of the country; (iii) organize meetings to approve projects; (iv) periodically evaluate the impact of NGOs intervention on the national economy; (v) coordinate all activities of NGOs; and (vi) receive NGOs' activity reports. All proposals for new projects must be directed to the SPONG which in turn consults with the national services involved. Contact is then established between the NGO in question and the national services who will work together for the elaboration of the project. The elaborated project proposal is subsequently discussed by the Ministry of Plan and Cooperation. Once approved, the project is signed by the Minister of Plan and Cooperation, the Permanent Secretary (SPONG), the Minister of Health and Social Affairs (in case of health/social affairs project), and the NGO concerned. The extent to which SPONG has an impact on directing health activities has not been assessed. It is believed, however, that its mandate may be too ambitious, and its accomplishments limited. 2* Ministtre de la Santd Publique, CHEMA/SCET, ao9t 1989. Etude du Secteur de la Santd: Vol.5, Approvislonnement en Mddicaments. 2 Ministire du Plan et de la Coop4radon, 1988. Secritarldat Permanent des ONGs. Les ONGs au Tchad. -24- E. rganiailon of Health Seim 1. 3.48 The public sector health services system* in Chad is divided into three tiers (Anna Level I (Periphery) - Health and Social Centers (health posts; clinics; infirmeries; centres de santd; liproseries); District Hospitals Level II (Regional) - Regional Hospitals Level III (Central) - National Institutions; Central Hospital - CNAR - ENSPSS - National Laboratory 3.49 As of 1990, there were 451 health facilities of which 294 (65.2%) were operated by the public sector (18 by the Ministry of Defense), 109 (24.2%) by the church-related sector, and 48 (10.6%) by other private organizations, mainly industries (Ane M .L). 3.50 In Chad, referral facilities are those hospitals with more than 200 beds, as well as health centers with a bed capacity of less than 200. Given such a definition, there are only 31 referral facilities in Chad or 0.58 facility per 100,000 population. This ratio has been decreasing with an increase in population and the number of facilities remaining the same (0.59 in 1989) (the WHO norm is 1 per 10,000). As for primary care infrastructures (i.e., infirmaries, clinics and health posts), there are about 334, or 6.2 per 100,000 persons, with almost no change in number and geographical distribution since 1988 (Anne&.IL.Zn.2). 3.51 The number of hospital/health center beds per 100,000 for the country is estimated at 76 or 1,316 persons per bed (among the least favorable in Sahelian countries where the estimated number of persons per bed is 600 in Gambia, 775 in Senegal, and 1,302 in Mauritania). According to UNICEF estimates, 60% of the population live at least two hours walking distance from a health center. There are wide variations between regions, the Lac and Biltine regions having the lowest ratio of hospital/health center beds per population compared to N'Djamena, Logone Occidental and the Moyen Chari which have the highest ratio (Einr A below). Regional variation is also observed at the primary care level with BET and Logone Oriental having the two highest ratios of primary care facilities to population. However, what may appear as a favorable situation in the BET region is mostly due to the low population density, the vast land area and, therefore, most likely a long travel time to the health facility. 3 A number of Government-owned health facilities are being operated by NGOs. Such facilities are included in this section. -25- Pigur A Beds/PJ a I M Ierso b. $-L? IM NDJAMNA I M CASA*A EOIRA E I 1 ANSU *ALAC EES MOMtNCRARt TANDJILZ USatIE - -MS- 0 20 40 60 80 100 120 140 160 3.52 There are two maternitispubliques (one in N'Djamena and the other one in Moundou). Other than the limited number of private clinics, the maternIM Is the only public facility in N'Djamena for medically-assisted deliveries. Devastated by the war, it has been partly rehabilitated but still suffers from inadequate funds, equipment and personnel. Specialized pediatric care suffers from similar problems. The 59 pediatric beds in the N'Djamena Central Hospital serve a growing population of children (about 46% of total population), or one bed per 4,896 children. 3.53 Specialized facilities are operated and supported by voluntary agencies (church organizations) with special emphasis on conditions such as leprosy and the handicapped. There are eight leprosy centers in the country run by the Raoul Follereau Foundation. Several organizations collaborate with the MOPHSA to care for the handicapped in Chad; among these are the Association d'Entraide des Handicapis Physiques du Tchad (AEHPT), the Association Nationale des D&Ijlems Audltyfs du Tchad (ANDAT), the Centre de Ressources pour Jeunes Aveugles 4 N'djamdna and the Centre National d'Appareillage et de Rdiducation (CNAR). The Central Hospital in N'Djamena has a rehabilitation facility and, with the support of the Red Cross and SECADEV, the parochial center in N'Djamena makes prostheses and provides physiotherapy services. 3.54 The physical condition of health facilities varies across Chad, depending in part on security conditions and accessibility, but equipment availability is mostly very poor. Only about half (55%) of all health facilities and one-third (36%) of public ones have a water supply within the building." Electrical supply is available in only one-fourth of the facilities and less than 10% have telephone or radio communication systems. Equipment is in disrepair at all levels of the system, 1 Detailed information by region and type of facility is provided in a report by CHEMA/SCETand in volume B of the statistical yearbook (Ministre de la Santd Publique CHEMA/SCET. August, 1989. Etude du Secteur de la Santd: Vol. 7, Infrastructures Sanitaires). -26- particularly in primary care facilities where essential equipment such as a baby scale, measuring apparatus, sterilization equipment, microscope and a refrigerator are generally unavailable. A wide variation exists with respect to the physical condition of the buildings with most renovated ones being maintained in good condition (49% of total facilities) (Annex R.6R..3. 3.55 Generally, health facilities are severely lacking in logistical and communications support to carry out their responsibilities. Consequently, central office personnel are rarely able to go to the field, and regional level administrators can only Intermittently carry out their supervisory and management responsibilities throughout the territories. Virtually all vehicles at the disposal of the various levels of the MOPHSA are provided by, and for the use of, foreign assistance personnel and projects. Generally, the central level has about 47% of all vehicles, 32% of motorcycles and 39% of bicycles. Limited transport seems to be more severe in the two regions of Logone Oriental and Tandjile. 2. Health P M s 3.56 The specific services and programs which have received the most attention by the MOPHSA and International donors have been implemented with varying degrees of success and have had unequal impact. Many of those programs are components of the stated national PHC strategy and their locus has changed with the reorganization of the MOPHSA. Not all existing programs will be discussed in this report as some of them are just starting or are in the process of being redesigned (malaria, goiter, dracunculosis, and acute respiratory infectious programs), and others are limited to certain geographical areas (onchocerchiasis and trypanaosomiasis in Moundou). The IEC and nutrition programs are discussed in Sections II and IV, respectively. 3.57 MCH gpram. The MOPH established in 1984, a Maternal and Child Health (MCH) Service in the Division of Public Health with the mandate of developing a national program and strategy for reducing Chad's high infant and maternal mortality rates. To reduce the maternal mortality rate, the MCH service proposed to focus on a variety of pregnancy monitoring services; protection of pregnant women against tetanus, malaria, anemia, and syphilis; nutrition education; and family planning education. To reduce infant mortality, the MCH service proposed to focus on growth monitoring; oral rehydration therapy (ORT); and vaccinations. Nevertheless, the program had little impact and suffered from the same problems as other services in Chad, namely inadequate training of health personnel; logistical and communications problems; inadequate equipment and maintenance funds; cultural differences between health personnel and the population; unavailability of common drugs; and difficulty in promoting preventive vs. curative services. In addition, responsibility for providing such services was with the social centers which were, until the recent reorganization of the MOPH, institutionally independent of the MOPH. Even with the new organization of the MOPHSA, attempts at integrating MCH and nutrition into PHC services have met with varying degrees of success. 3.58 In the newly mandated organization of the MOPHSA, a division of MCHI/Family well- being (Blen-Etre Famtal-BEF)/Nutrition was created under the Directorate of Health Activities. Integration of these activities is expected to take place at the various levels of care, namely hospitals, health posts, as well as social centers and MCH satellites. While many of the satellites and social centers continue to operate in isolation of other PHC services, in those centers which have been converted into PHC facilities (as in the Moyen-Chari), collaboration between the various units has resulted in improved MCH services. 3.59 Family well-being program (BEF). The National Service for Family Well-Being in Chad was created in 1987 with the inauguration of the center Assiam Vamtou. It aims at protecting and promoting MCH through spacing of births, controlling STDs and sterility, and through IEC activities for health in general. In 1989, seven other centers had started offering BEF services in N'Djamena, the personnel training and contraceptive supplies being provided by USAID and UNPPA (para 2.10). -27 - 3.60 xandd rmom of mnzatio . The EPl in Chad is planned and administered as a special program within the new Directorate of Health Activities. The program was launched in January 1985, with the support of WHO and UNICEF, and had the short-term objective of vaccinating 75% of children (0-2 years) and women of reproductive age by 1990. The EPI relies on a combination of strategies and, accordingly, on different activities: (1) under the "fixed" strategy, all immunization activities are carried out in existing health facilities thus aiming at a population living within a 5 km radius of a health facility (Zone A); (ii) the "advanced" strategy covers an area of 5-20 km around the facilities, with the EPI agents visiting Jhe population (Zone B); and (iii) "mobile" strategy, carried out by the mobile teams, aims particularly at the population living beyond the 20 km radius, particularly the nomads (Zone C). A fourth strategy of "acceleration", added in 1986, has allowed the vaccination of 64% of children (0-23 months) and 73% of women of childbearing age during the period of October 1987-January 1988. Given the success of this strategy, it has been extended to other parts of the country.3 3.61 The evaluation of the EPI carried out by UNICEF shows that although noticeable progress has been made since 1985, particularly in the organization of refrigeration units (chatne defrold) and personnel training, substantial efforts need to be exerted at all levels to reach the 75% immunization coverage objective. Given the incomplete health information available, the epidemiological impact of the program is insufficiently measured. Nonetheless, the BSPE reports indicate that complete vaccination coverage has increased from 2% in 1984 to 20-30% in 1990 with wide variations being observed across regions (the highest coverage being in the Logone occidental). Measles is now ranked 16th among causes of mortality compared to a ranking of 6th in 1977. 3.62 Oral rehydration therany (ORT). The national program to combat diarrheal disease was developed in 1984 by the MOPH in response to the high number of diarrhea-related deaths occurring in children. The program's goals, to be achieved by 1990, were: (a) distribution of ORT packets to 70% of the population; (b) 25% reduction of child deaths associated with diarrheal disease; (c) reduction in the incidence of diarrhea among children under 5 by 15% in rural areas and 30% in urban areas. To achieve these goals, the Ministry's program proposes to: (a) improve treatment of diarrheal diseases by promoting the use of ORT packets through educational campaigns and use of the packets in treatment by MOPH personnel; (b) improve MCH services delivered by MOPH/MOSA personnel; (c) strengthen MOPH environmental sanitation activities; and (d) establish a system of systematic epidemiological monitoring. The program has been supported by UNICEF who has agreed to provide 1.5 million ORT packets annually for two years, in support of the national program, to be distributed by the national pharmacy system (PASP). USAID has also agreed to fund a project that would provide the educational materials and training for health workers to be administered by AFRICARE, with short-term assistance from PRITECH." 3.63 Services for the handicapped. Provision of medical and social services for physically handicapped people is a major political and health issue in Chad. While a portion of this population had been afflicted by polio and other crippling diseases, the majority of the physically handicapped have been wounded in recent wars in the country. The Association of Chadian Handicapped Persons estimates that I MOPH. 1985-87. Rapports Annuels. Programmes Elargis de Vaccination (PEV). I UNICEF/Chad, 1988. Preliminary Analysis of the Vaccination Campaign of N'Djamena. 14 Health Policy Institute, EMCORP, Boston University: April 1986. Health Services Development in the Republic of Chad. -28 - 10% of the population suffers from various disabilities." The handicapped population in Chad is heavily concentrated in the capital (30%). About 50% live in N'Djamena, its region (Chari-Baguirmi), and two neighboring regions of Kanem and Lac. About half of the war handicapped live in N'Djamena while in contrast, most of the handicapped children live in the southern regions, where the incidence of polio and meningitis is reportedly high. The visibility of this problem, particularly in N'Djamena, has made the situation of the handicapped a high priority health problem of the Government as well as of several donors, particularly the AfDB and UNDP. 3.64 Overall, there is little capacity in Chad to provide physical therapy, prosthetic devices, or vocational/social rehabilitation. In N'Djamena, the following facilities are available: at the Central Hospital - surgery, curative and rehabilitative care; at the Kabalaye Center operated by the SECADEV - a limited number of prosthetic devices as well as physical therapy; and at the CNAR - orthotic devices, tricycles, crutches and physical therapy. Outside N'Djamena, there are six facilities, two of which - Logone-Oriental and Chari-Baguirmi - provide vocational rehabilitation and physical therapy for adults. The remaining four, also located in the Southern provinces, provide specialized surgery, some physical therapy and/or prosthetic devices for polio cases, primarily children. With the exception of one facility, they are operated by church-related organizations. Despite their limited resources, some of these facilities such as the Kabalaye and the Benoye Centers demonstrate remarkable quality of care; however, they are clearly unable to meet the increasing needs of the country. F. Utilization and Ouality of Health Services 3.65 Most public PHC facilities in Chad are underutilized, in spite of serious and abundant health problems. This underutilization is attributed, to a great extent, to a lack of medications and to the public's low level of confidence in the services provided, in addition to difficult access in some areas and seasons. Most of the health problems of the Chadian population (80-90%, according to MOPHSA estimates) could be dealt with by a basic package of health services available at the health center level or below. However, the mix of services available at Chad's peripheral MOPHSA health facilities is limited and underemphasizes (or practically omits, in many facilities) preventive care." The number of first visits to health services reported for infants (0-11 months of age) is low (25,000 new visits for an estimated 228,000 members of the age group in 1990) and it decreased significantly, by 29%, between 1988 and 1990. In 1990, the total number of preventive visits for infants 0-11 months was only 75,250. Moreover, even curative services are underutilized: the number of new curative cases per 1,000 population in 1990 was reported to be 332 (and 329 in 1989), whereas 1,000 such contacts would be a reasonable target. Hospital statistics also indicate a low rate of utilization for most facilities as reflected by a bed occupancy rate of less than 50% reported by about half of inpatient facilities. On the other hand, these same facilities reported average lengths of stay of over ten days (US hospitals report an average length of stay of seven days), an indication that a large proportion of inpatients represent "severe" cases. 3.66 The quality of MOPHSA health services is limited by several factors. First, most personnel lack training, much of the training received is less than adequate for the tasks which the "Statuts de I'Association des Handicapes Physiques vivants 4 N'4/amina", Association d'Entraide des HandicapOs Physiques au Tchad. 3 The 1990 Annuaire Statistique, for example, comments (p. 163) that with regard to preventive care: "es donnOes ne sont pas tr4s flables pour le moment car dans la plupart des formations la notion de soins prdvent(fs n'a pas Ntd blen comprise et 1 n y a en gondral pas de programme organtsd." -29 - workers must take on, and the skills of many of those who have received training are inappropriate given their jobs. Second, scarcity of drugs (also linked to the inappropriate use of drugs) severely limits adequacy of treatment. Third, the low levels of operating budgets for health facilities, as well as the poor state of maintenance and repair, limit essential nondrug supplies and provide unattractive, and often unsanitary environments for patient care. G. Health Manpoe 1. Current Manpowe Situation 3.67 Chad's current health manpower situation presents several major challenges to the quantitative and qualitative strengthening of the country's health services. The majority of Chad's health workers have had no professional training in health. An inventory of health personnel, carried out in 1988 and partially updated (mainly regarding physicians) in 1989 and 1990, forms the basis for the health manpower sections of the MOPHSA's AnnuWre Statistique. 3.68 The dramatic 31% increase in the total number of heakh personnel between 1988-89 and 1990 is to a large extent explained by the Ministry of Defense (MOD) having included untrained health workers in their 1990 report, whereas the earlier MOD reports counted only trained personnel. The MOPH reports that of the 5,129 health personnel in 1990, 80.8% were in the public sector, 13% in religious missions, and 2.8% in the private sector. In addition to the 4,321 public sector personnel, there are 568 Social Affairs personnel, resulting in 4,889 total public sector personnel. The social affairs category does not exist in the church-affiliated and private sectors. The assumption in the health financing section of this report that 4,000 of the 4,889 public sector health personnel are paid by the MOPHSA (with the rest being expatriates and others paid by project or local funds) appears reasonable. Of the 164 physicians, only 103 are Chadians. Table Ill-2: Health aersodnel bM qualification and status in 1990 Church- Public affiliated Private Total Physicians 142 14 8 164 Qualified personnel' 1,464 304 43 1,811 Unqualified health care personnel 252 55 11 318 Personnel without professional training 1,344 162 50 1,502 Administrative personnel 258 25 13 296 Maintenance personnel, drivers 899 106 17 1,038 Total 4,321 666 142 5,129 'Includes dentists, pharmacists, state-registered nurses, and other technicians with formal training. 2 Includes nurses with less than two years of formal training. -30- 3.69 There is a severe shortage of qualified health care personnel. Compared to WHO norms, the ratios of provider to population (1990) are as follows: Physicians: 1/32,830 inhabitants (vs WHO 1/5-10,000) State-Registered Nurses: 1/33,862 " (vs WHO 1/300) State-Registered Midwives: 1/8,529 women of fertile age and children 0-4 years of age This scarcity of personnel is aggravated by inadequate training, poor working conditions, and skewed geographic distribution. WHO "norms" or other idealized ratios, while interesting for comparison purposes, should be paid much less attention than efforts to determine how efficiently and effectively currently available health personnel have been deployed and are performing, and what can be done to increase their efficiency. Lack of training, or inadequate training (competence in managerial skills is almost nonexistent among health workers), combined with the unavailability or scarcity of key inputs such as drugs and supplies, grossly limits the effectiveness and efficiency of most of the MOPH's health personnel. A large proportion of existing health care (36%) and maintenance/support (20%) personnel is unqualified (the figures are much lower in the church-affiliated and private sectors); and even those who have benefitted from formal training and who, thus, are considered qualified are often unable to provide adequate care, as a sizable proportion (about 20%) are handicapped by prolonged illness, physical disability or just old age. Moreover, the lack of controls and medical legislation results in diagnosis and even treatment of patients by unqualified personnel (i.e., garpon de salle, manoeuvre). The geographic distribution of MOPH personnel is also strikingly distorted. About 30% of total health personnel are posted in the capital city (Amex M.7). Finally, of the 164 physicians in the country, 108 (65.8%) are in N'Djamena, 9.7% in the large towns (Moundou, Sahr, Ab6ch6, Bongor), and 24.5% in the rest of the country. Of the total of 88 midwives, 56 (64%) are in N'Djamena. 3.70 With respect to social affairs, the personnel seems to be adequate in number. However, they too suffer from an unclear role definition, particularly since the implementation of the new health policies and reforms. 2. rections of RQuired/Feasible Manpm 3.71 In the process of preparing the health coverage plan, the MOPHSA carried out a detailed analysis of personnel requirements by administrative level (central, intermediate and periphery), by prefecture, as well as by category of personnel. While the methodology is useful, the data obtained and presented in the preparatory document for the Round Table contain many errors and therefore are not used fully in this report. The overall conclusion, however, coincides with that of many other reports,3 36 indicating that additional personnel needed for implementation of the new coverage plan and the MOPH reorganization totals about 500 persons, mainly registered nurses, pharmacists, technicians (laboratory, dental), and social workers. These reports confirm that Chad's health manpower problems are not so much a result of inadequate numbers of personnel than of inappropriately qualified, maldistributed and ineffeciently utilized personnel. 3 See Summary in Frangois Orivel's "Etude du Secteur Santd au Tehad. Priparaion de la Table Ronde sur le Secteur. Commentaires sur les Docwnents Prdparatoires," IREDU-CNRS, Dijon, February 1991. 38 Jean Perrot, Economic and Financial Analysis of the Health Sector in Chad, WHO- PCO/ICO - Geneva, February 15, 1992, page 19. -31- Figure B Medical Doctors nWr 100.000 Persons or Prefecture BATHA BILTINS B..T CHARI-BAGUI. RURAL NDJAMENA GURRA KANEM LAC LOGONE OCC. LOGONE ORL MAYO-KEBB 1 MAYEN-CHARI OUADDAI SALAMAT TANDJILE ENSEMBLE DU PAYS -MMMA 0 5 10 Is 20 3.72 Health manpower projections and proposals to improve the manpower situation must be examined within the context of the extremely tight financial constraints of the country. The hiring of additional staff could take place over a period of years, as centers open, and in accordance with the development of the capacity to support and supervise them. The necessary redeployment of some personnel away from cities (especially N'Djamena) to smaller facilities will need to be accomplished at the same time. The planning and implementation schedule of the retraining, hiring and redeployment of personnel will be a crucial part of the execution of the National Health Development Plan. It will need to be carefully taken into account in budget and foreign assistance planning. 3. Training 3.73 The principal health training institution in Chad is the Ecole Nationale de Santi Publique et du Service Social (ENSPSS). Nurses and other health personnel are also trained at mission-operated schools associated with mission hospitals, and informal on-the-job training of lower level personnel is provided by staff (by those who are so inclined, and with little or no control) at health facilities throughout the country. A few NGO students, paid for by their agencies, are trained at the ENSPSS along with government-sponsored students. While the ENSPSS trains an adequate number of personnel, the quality of training is very poor. 3.74 Quantitatively, the ENSPSS has graduated a much larger number of persons than was envisaged in the three-year plan prepared in the context of the UNDP projece aimed at improving its situation. * Projet Chad/85/007. - 32 - TABLE E-3: Health Mannow Graduates in 1987 1988 1989 1990 1991 Total Nursing 83 35 46 33 197 Social work 72 22 23 7 124 Child care 12 14 19 10 55 Total 1st cycle 167 71 88 50 376 Registered nursing 25 35 37 40 50 187 Midwives 15 26 24 25 29 119 Social work - 22 22 23 25 92 Sanitation 35 20 15 - - 70 Total 2nd cycle 75 103 98 88 104 468 rotal Graduates 345 169 176 154 844 Eg ge: PNUD, Rension d lWle lonak de Santi Pllau . de Skur*6 Sodale..NSPSS). Rappori de la mission tripartite d'dvaluation, Chad, Mars 1992, p. 23. A total of 844 were graduated in the past three years, although the plan was to graduate 354 persons. Given the current situation of the system and the capacity of the school, both physically and pedagogically, this excess is undesirable and reflects among other things the laxity of admission and graduation standards and procedures." 3.75 Qualitatively, the ENSPSS has been the subject of concern, and much frustration as shown in the recent evaluation of the three-year project, executed by WHO.41 There is a clear need for the ENSPSS to plan and improve its training program and to strengthen its staff. The faculty consists of 27 permanent faculty members (of whom only eight have had specific pedagogical training) and 45 adjunct faculty (vacataires) (with little control over even the content of the vacatalres' teaching). There is not sufficient personnel to supervise students' practical training in health facilities. Furthermore, the current curricula are not pertinent to the needs of the country and should be revised, coordinated, and updated within the framework of a National Development Plan and according to the revised roles of the personnel. The excess number and underutilization of water and sanitation technicians in Chad is a good illustration of the irrelevance of their training to the needs of the country. A study by the Institut Tropical Suisse (ITS)' which has defined the expected roles of key health personnel, has yet to be taken into consideration by HNSPSS management and used in curriculum revision. I There are practically no dropouts or failures; indeed, all students admitted to the school graduate. 41 PNUD, Extension de I'Ecole Nationale de Sand PublaIue et de Securitd Sociate ENSPSS). Rapport de la mission tripartite d'dvaluation, Chad, Mars 1992. 4 Vincent Litt, (check with Anwar) -33 - 3.76 The ENSPSS also trains social workers, in common training with nursing students in their first year. After graduation, the social workers' job assignments include clinical immunization and preventive care tasks which are also carried out by nurses. This poses problems for training, but the resolution of these problems will depend upon an adequate and realistic definition of roles for social workers and upon determination of the skills requirements and quantitative personnel requirements corresponding to those roles within the system. 3.77 Another source of concern is the administrative context of the ENSPSS. Legislative texts have been developed, with the help of donors, to form a Board of Administration for the ENSPSS and to give the institution an independent administrative status. These texts have yet to be adopted. Meanwhile, a degree of uncertainty prevails regarding possible plans to integrate the ENSPSS and the Faculty of Health Sciences without any careful study of the full implications of such integration. As a result of this confusion and as an illustration of the lack of clear decisionmaking, the newly constructed building for the ENSPSS remains unoccupied, and training of health personnel continues to take place in the existing run-down facilities. 3.78 In the face of this bleak situation, the major external assistance agencies active in Chad are focusing on health personnel development (HPD), including the training of health workers. HPD is one of WHO's areas of emphasis. The EEC/EDF program has focused on training of the Provincial Health Directors and their Deputy Directors. Swiss Development Cooperation, through ITS (Phase 7, July 1990 to June 1993), is supporting a major component intended to support the MOPHSA in the development and implementation of a comprehensive and coherent health personnel development policy, particularly in terms of training and through the national health planning process now underway. The AfDB has also expressed interest in cofinancing support in this area. USAID's Child Survival Project includes support for the establishment of a MOPHSA training center which could support training of personnel for several provinces. 3.79 In 1990, 158 Chadian students affiliated with the MOPHSA were studying abroad, of whom 98 were studying medicine. Others are studying medicine overseas without official recognition or support. If these numbers are maintained, possibly 13 to 15 Chadian physicians per year would continue to return to Chad after completing medical studies overseas.3 This number represents a substantial annual increase of about 13% over the current number of Chadian physicians in Chad. It also approximates what is estimated to be the limits of Chad's absorptive capacity in terms of financial and technical support for physicians in public service. 3.80 With the understanding that many overseas Chadian medical trainees prefer to remain overseas and are therefore lost to Chad's health services, the GOC opened a Faculty of Health Sciences in N'Djamena in 1990, admitting a class of 47 students. The medical faculty was a subject of controversy among donors. Today, there is growing consensus that the faculty, even if it were to produce reasonably well-trained physicians, will distort MOPHSA's personnel balance, its budgets, and its expenditure patterns, probably with negative effects on the MOPH's contributions to health in comparison with other patterns of operations and expenditure. Donors for the most part are not supportive of further development of the medical faculty, and the GOC has not admitted another class since the initial one. WHO arranged limited technical support for the initial planning and operation of 43 The return of trained physicians to their home countries (if they want to practice medicine) is encouraged by increasingly restrictive licensing practices, the glut of physicians on the European market and the consequent availability of European physicians for work outside of Europe, as well as the growing oversupply of physicians in many developing countries. -34- the medical school (primarily from Algeria, which has an excess of physicians and of medical school capacity). The GOC planned to seek bilateral technical support from Algeria, although recent events in Algeria have made such support unlikely. 3.81 The Chadian health care system Is heavily focused on physicians who are perceived by many (including some donors) to be the only type of health care professional capable of managing health resources at all levels. Given the costs of training physicians and Chad's scarce resources, it is essential to change this perception. Non-physician health services administrators, who could be trained and employed at a lower cost than physicians, could replace many physicians presently in administrative positions. This would enable those physicians to return to clinical practice, thereby increasing the number of posts requiring physicians' specific skills which could be filled. Physicians are overly concentrated in N'Djamena, as many of them hold managerial positions (mostly directors of donors-funded projects). Correction of this overconcentration would also improve the effective availability of physician services to the population. H. Phamaceuticals 1. The Pharmaentical Supply and Distribution System 3.82 The supply and distribution systems are dominated by two organizations - the PHARMAT, regulating the private sector and the Pharmacle d'Approvisionnement du Secteur Public (PASP), regulating the public sector. There is, in addition, the private for-profit sector, essentially voluntary and church-affiliated, and the military sector for which information on drug procurement is not available. 3.83 The-nubistQ r ensures the drug supply for all health facilities that depend on the MOPH. In 1988, the total actual resources allocated for this sector were about CFAF 500 million or about CFAF 100 per capita (US$0.4), mostly from donors. The sector is supplied through two distinct channels: (i) PASP in which is integrated into the EEC project, FED VI; and (il) the various donors: MSF (Mayo-Kebi), FAC (N'Djamena, and Moundou hospitals), ITS (Bousso, Kyab6, N'djamena Hospital), German NGO (Abdchd hospital), and UNICEF for its various programs. Each of these programs adheres to the existing Essential Drugs List (EDL). According to the agreement signed with the Government, donors provide drugs for the zone in which they work. As a result, the availability of these resources varies with the zone of intervention of the various donors, creating a large degree of disparity and placing hospitals and Southern prefectures at a disadvantage as shown in Table J-4 below. The IDA-financed SDA Project as well as the project of the Italian Cooperation are expected to complete the coverage of the remaining prefectures not yet benefitting from such arrangements. -36- implementation of cost recovery. Through IDA's SDA Project, the Swiss are providing support to three sub-prefectures where the Essential Drugs Program (EDP) is strictly endorsed. Because donors do not Intervene In those regions, the hospitals of Moundou, Sahr, Ab6ch6, and Bongor, in addition to the N'djamena Central Hospital, do not have a functioning pharmacy service. Theoretically, the distribution of medicine to health facilities is done every three months. However, in reality, it is determined by the availability of fuel and vehicles, as well as pharmaceuticals. Distribution is totally centralized as there are no intermediate storage facilities. Donors have, however, initiated activities towards the decentralization of distribution and are studying the feasibility of creating a distribution network for the public sector. 3.86 The Udae sector is represented by PHARMAT - held by both Chadian Government and private funds - which has a monopoly on this sector, thus barring price and quality competition. In addition to the monopoly, high prices are due to the fact that PHARMAT does not follow the essential drugs list and the generic basis for its procurement. This misallocation of resources tends to perpetuate consumer perceptions that brand name and dispensable drugs available outside of the Government's health system are preferable. In 1988, the market volume for PHARMAT totalled about CFAF 943 million or about double that of the public sector. N'Djamena is the focus of its activities, although it has a regional store in Moundou. PHARMAT supplies all the private pharmacies and pharmaceutical stores in the country as well as the health facilities of private firms such as COTONTCHAD. It may also serve as a supplier to the public sector. When it was created, this monopoly was justified by the laxity of the public system at the time. However, with the help of donors -particularly the FED project - and with the implementation of the new organigram that separates PASP functionally and physically from DPHLAM, the current situation does not justify a monopoly in the private sector. 3.87 The church-affillated sector is supplied through many sources, the major one being UNAD which centralizes the supply for the following organizations: BELACD of PALA, BELACD of MOUNDOU, BELACD of SAHR, SECADEV, BEBAYLEM hospital, and KOYOM hospital. This voluntary sector represents a significant proportion of activities and meets a large part of the country's needs (the volume of this market in 1988, totalled CFAF 126 million). A conflict between this sector and PHARMAT, which claims monopoly over supply for all private (including voluntary) organizations, has been resolved for the time being. However, a longer-term resolution leading to a clear definition of roles is clearly needed. At the policy level, it has contributed to demonstrating the successful introduction of cost recovery in several parts of the country. 3.88 Parallel to these formal sectors is the ill drug market. Drugs sold on this market come from Nigeria, Cameroon, and Niger, as well as from thefts committed in the public sector. Although some control is exercised in N'Djamena, this market operates almost freely at the periphery making it almost impossible to control the quality and the quantity of drugs utilized. 2. Loal Production 3.89 Currently, the country has no capacity for local production of pharmaceuticals. However, a project (Socidtd Industrielle Pharmaceuique du Tchad- SIPT) is currently underway for the creation of a production plant for a number of products ranging from intravenous perfusions and ORT, to aspirin and chloroquine. The results of a feasibility study that was undertaken and which served as the basis for the selection of the physical site, are presently the subject of controversy in the country. Given the current state of the pharmaceutical sector and the lack of quality control mechanisms at the level of DPHLAM, this project seems premature; moreover, it could be a very costly mistake to the country, not only economically but also in terms of health hazards. -35 - Table M-4: Donors' Intervention by Geoarahica Areas Annual Covered Amount Level of Facilities Included Donor Budget Population per Capita Coverage (in CFAF millions) (in thousands) (in CFAF) (123)1 Vie FED 220 2,000 110 1 2(3) Ab6oh6 hospital MSF 70 700 100 1 2(3) Bongor hospital PAC 190 900 210 3 N'Djaraena and Moundou Hospitals DMPSR 35 5,000 7 123 CAMS 50 500 100 3 Abdoh6 hospital ITS 16 150 100 12 Rural area 8 500 16 3 N'Djamena hospital UNAD 126 1,000 125 123 Private hospitals and donations PASP 44 1,800 25 123 N'Djamena, Sahr and Moundou hospitals PHARMAT 750 500 1,500 123 SDA Project 150 500 300 1 N'Djamena city (Urban area) SDA Project 75 500 150 1 2(3) Moundou/Lai (South srea) 1 = district level; 2 referral level; 3 = specialized hospital. lurgo: MOPH, Chad, De=Wwns Aeelter de SaWt Pftblmis 17-24jda, 1989. 3.84 At the gtl level, and until the newly-mandated organization of the MOPHSA is put into place, the PASP remains under the Directorate of Pharmacies and Laboratories (DPHLAM) of the MOPH, a situation which hinders its development and minimizes the important role of the DPHLAM in quality control. It has no autonomous structure and no separate operating budget. Instead, it is a puzzle of juxtaposed "stores" attributed to the various donors who utilize different procurement, management and distribution systems, thus adding to the complexity and confusion of PASP's role. Whenever purchases are made from the Government budget, they are restricted to the national market, thus forcing the PASP to resort to PHARMAT and its noncompetitive prices (para 3.86 below). 3.85 At the peripheral level, the hospital pharmacies and health facilities rely almost entirely on donors for their supplies of pharmaceuticals. They intervene through donations managed and distributed by PASP or through projects. The FED VI/VII project is the most important because not only does it provide assistance to the intermediate and peripheral levels, but it also attempts to reorganize the pharmaceutical sector through the creation of a supply system based on: (i) improvement of PASP's management capacity; (ii) creation of prefectoral pharmaceutical stores; and (iii) progressive -37 - 3. Ot - 3.90 The current pharmaceutical legislation in Chad is obsolete and irrelevant given the present Chadian context. It is based on French law (loi 28) concerning pharmacy practice and dates from 1985. The adaptation of this legislation to the current needs of the country is clearly needed. 3.91 Related to legislation is the subject of inection Nd control. Currently, DPHLAM is nonoperational due to the lack of organization and unclear definition of the role of the division, as well as the shortage of qualified personnel and material resources. As a result, procedures for registering drugs (visas d'enregistrement), and for drug quality control (laboratory for analysis, definition and adherence to norms of manufacturers, packaging, transport, storage, and prescribing) are nonexistent. Their Importance is confirmed even further by results of surveys that showed the irrational use of pharmaceuticals in the country. I. Health Sector Expenditures and Financing" 3.92 The financial analysis of the health sector covers four areas: (I) trends over the past seven years; (ii) detailed Government' expenditure analysis for the years 1990, 1991, 1992; (iii) capital expenditures on health and social affairs based on the Public Investment Program (PIP); and (iv) projections for the coming decade. 1. Recent Tnds 3.93 Health has not been a national priority In Chad, despite offidal pronouncements. While the absence of accurate financial data makes a precise analysis difficult, recent trends indicate that the share of the Government budget allocated to health has been around 4% over the past few years, lower than the 5% average for Sub-Saharan Africa, and considerably less than the 8% recommended by WHO. The sharp increase in 1991 is only an indication of the fusion of the two ministeries, Public Health and Social Affairs/Women into one, the Ministry of Public Health and Social Affairs, rather than a sharp increase in real allocations to health. The lowest share was observed during the serious economic crisis of 1987/88.10 " Source of data: Jean Perrot, Economic and Financial Analysis of the Health Sector in haW, WHO-PCO/ICO, Geneva, January 1992. a Although the military provides health services to its personnel, information on on those services is not available. Therefore, in the present context, "Government" refers only to the MOPHSA. * Data used are from two sources: (1) Annualre des Statistiques Sankaires du Tehad, BSPE, MOPHSA, up to 1990; and (2) the Plan d'Orlentaton of the Ministry of Plan and Cooperation. It should be noted that the MOPHSA's 1990 statistics do not correspond to the data appearing in the Plan d'Orentadon of the Ministry of Plan and Cooperation. - 38 - Table 111-5: Health Budget Trends (In current CFAF millions) Government Budget Health Expenditures Govt.Health Govt.Health Year Authorized Actual Authorized Actual Authorized Actual % % 1985 39,836 25,167 1,547 1,033 3.9 4.1 1986 42,550 27,711 1,272 1,053 3.0 3.8 1987 25,401 24,768 740 708 2.9 2.9 1988 27,114 30,972 883 792 3.9 2.5 1989 39,154 42,235 1,624 1,280 4.2 3.0 1990 40,107 39,709 1,720 1,535 4.3 3.8 1991 46,412 50,074 2,442 2,265 5.3 4.5 3.94 In contrast to the behavior of the overall Government budget, actual expenditures in the health sector are consistently lower than the amount authorized. For example, in 1990, CFAF 50 million were allocated to pharmaceuticals, but none was spent. In a poor country like Chad, this is normally an indication of "tight" resources. It may also be explained by the existence of administrative problems: the repartition of credits among departments of the MOPHSA and, particularly, the regional repartition, takes up to five months which implies that departments only know in April or even May, the amount of resources available. The delay is the result of cumbersome administrative procedures and a politicized decisionmaking process for the repartition of credits among departments. As bills must be cleared before the end of November, this leaves seven months for their clearance. Another administrative problem arises from the interaction of the MOPHSA with several other Government agencies. Clearing bills for payment is a complicated and time-consuming process, involving the Government control procedures, the Ministry of Finance, and the Treasury. 3.95 As expected, while there are large discrepancies between actual and allocated operating expenditures, few differences are noted for personnel expenditures. The share of actual operating expenditures has, however, increased over the years. In 1990, actual operating expenditures accounted for about 25% of total actual expenditures (30% for budgeted figures) compared to 12% in 1989 (A=nE m. 3.96 A large share of public spending for health (an average of 76% for the 1985-90 period) is consumed by personnel. Even by Sub-Saharan Africa standards (in Senegal, it ranges between 64 to 73%), this percentage is very high, leaving inadequate finding for other key recurrent costs, such as maintenance of facilities and equipment, and drug supplies. 3.97 Except in 1985, eternal aid has represented about 80% of the country's health expenditures which places Chad In a situation of extreme dependency. Assuming a distribution of 15% for capital investment and 85% for operating expenses (exact ratio unavailable), external aid in support of operating expenses was three times greater than Government outlays for this purpose in 1990. - 39 - Table III-6: Eubi Sector lth Ejditurs (In current CFAF millions) 1985 1986 1987 1988 1989 1990 Actual Government expenditures 1,033 1, 053 708 792 1,280 1,534 External aid 2,016 5, 081 4,731 5,411 5,995 5,541 Total 3,049 6, 134 5,439 6,203 7,276 7,075 3.98 Sore of Health.inancing. In 1990, the Government spent about US$1 per capita on health while allocations from external sources were about US$3.5 leading to a total public expenditure of US$4.5 (excluding household expenditures on health). Trends show that over the past five years, per capita health expenditures in constant CFAF (with a price rise of 5% per year) have remained stationary, or even slightly declined TablI7). To this figure should be added expenditures by households for the purchase of services, particularly medications, on the private market, as well as expenditures financed by church-affillated groups (e.g., BELACD, SECADEV) and other NGCs (particularly MSF). These expenditures, though difficult to estimate, have been quoted in the Government's Plan d'Orentation at CFAP 2 billion for 1990, a sum roughly equivalent to Government expenditures under the same heading. This sum primarily represents expenditures in the private health sector, since traditional services are likely to be paid in kind. Two surveys carried out in N'DjamenaP found that on the average, household health expenditures (including folk medicine) in 1988 totalled CFAF 438 per capita as compared to CFAF 1,224 in 1991. These figures are more likely to be lower in rural areas as modern health services are less accessible and traditional medicine more prevalent. Table m-7: Trends in Per Canit Ealth En diUM (in current CFAF) 1985 1986 1987 1988 1989 1990 Financed by the Government 204 203 134 146 243 285 Financed by external aid 398 981 892 997 1, 139 1, 029 Total 602 1,184 1,026 1,143 1, 383 1, 314 (excluding household out- of-pocket expenditures) 2. Government Expenditures: 1990 and 1991 Budget Analyses 3.99 The GOC's budget format is not conducive to highly detailed analysis of equity and efficiency in health financing, as it does not distinguish between administrative (central and regional) functions and operational functions or, within the latter, between the hospital and non-hospital sectors, and between urban and rural areas. However, several observations can be made: (i) while the share of health expenditures in the 1991 budget increased by almost 1% from the 1990 share, the increase is 4 Engute Mgre sar les conditions de vie des mnates t N'diamin Ministry of Plan and Cooperation, N'djam6na, 1991. .40- attributed to a sharp increase in the wages item, rather than in operating expenditures; (ii) a large part of the budget goes to the Department of Hospitals and Urban Medicine, which alone accounts for almost 50% of the personnel costs and does not reflect the Governments stated intention of according priority to primary health care; and (il) appropriations for drug purchases, which are very low (CFAF 8 and 18 for 1990 and 1991, respectively, per capita) were not used because of unavailability of funds. 3.100 Fee-for-service revenues from consultations at hospitals or health centers (CFAF 100) are transferred to the National Treasury with no guaranteed benefit for the health facility. The Government estimated revenues of CFAF 118 million under this heading in 1990, and CFAF 150 million in 1991. 3.101 Preparation of the 1992 budget. Given the lack of a macroeconomic framework and of a national plan prepared and accepted by all public sector actors, the Government's budget proposals for the health sector are unrealistic. For public health activities excluding social affairs, the MOPHSA's proposals are as follows: Table 1-8: Propoed Budmet for 1992 (in current CFAF thousands) 1991 Budget Proposed 1992 budget Wages 1,361,122 2,192,617 Operating expenditures 622,751 2,601,880 Total 1,983,873 4,794,497 These figures do not correspond to the 1991 figures presented in previous tables since Social Affairs expenditures are not included. 3.102 The 1992 projected increases in expenditures, while justified, are totally unrealistic given actual resource availability: of the proposed 61% increase in the personnel costs, one-third corresponds to the recruitment of 586 additional personnel, a decision made without the finalization of a health personnel plan and a national health policy document; operating expenditures are up by 420%; expenditures by the DAF, i.e., practically all operating expenditures, are expected to triple; the "purchase of medications item" is expected to increase about ten-fold. Accordingly, the share of health expenditures (excluding social affairs) in the Government budget would increase from 4.5% to 11% in a single year. More pertinent budget preparation procedures are clearly necessary. (The discussions held in preparation for the Donor Round Table should help to identify the broad lines of the sector's expected development.) 3. Capital Ependiturtes In the Health and Sodal Sectors Measured on the Basis of the PIP 3.103 Method of Analysis. The Ministry of Plan and Cooperation maintains periodically updated information on all ongoing projects. Table M-9 shows the PIP for health/social affairs as of October-November 1991. -41 - Table III-9: Health EMenditure. incuded in the PIP (in CFAP billions) 1990 1991 1992 1993 1994 Grants and subsidies 38.2 41.7 60.5 51.4 31.8 Loans 19.7 27.7 25.1 31.4 27.3 Total 57.9 69.4 85.5 82.8 59.1 The decrease in expenditures after 1992 is explained by the fact that some projects are coming to an end, and possible follow-up projects are not yet under way. It is worth noting that these figures might include projects that have not yet been signed (and perhaps will not be signed in the near future). 3.104 The classification used in the PIP does not distinguish between health and social affairs. The approach by field of action does make this distinction, but it classifies basic training projects under vocational training. For our purposes, we propose to adopt a specific system of classification with, on the one hand, projects that are totally, or to a great extent, "health" oriented and, on the other hand, "social affairs" projects, which have a fairly direct link with health. Projects that have no such direct links, such as the women's weaving project, will be excluded. Using these concepts, we obtain the following results: Table III-10: Breakdown of Health Expenditures in the PIP (in CFAF billions) Total Expenditures Capital Expenditures 1991 1992 1991 1992 Health 5.762 10.054 0.877 1.930 Social affairs 0.479 0.514 0.015 0.020 Total 6.241 10.568 0.892 1.950 3.105 For development projects, the health and social affairs sectors received 9% in 1991 and 12.5% in 1992 of the total PIP, an increase relating mainly to the development of three programs: UNICEF, up from CFAF 0.3 to CFAF 1 billion; Cooperazione Italiana, increasing from CFAF 0.2 to CFAF 2 billion; and USAID, increasing from CFAF 0.3 to CFAF 1.2 billion.4 Although the share of what may be regarded as actual investment within PIP expenditure is seen to rise from 14.3% to 18.4%, it is still considered a very small percentage of total health spending. As the GOC health budget a The N'Djamena hospital Construction Project, included in the 1992 PIP for the sum of CFAF 1.16 billion, has not been considered since the agreement has not yet been signed. On the other hand, projects classified as within the health sector by the PIP do not include IDA's SDA Project, representing US$26.9 million over five years, 25% of which for health sector activities. -42 - Is not sufficient to cover basic operating expenditures, projects tend to complement it and, therefore, finance a large proportion of recurrent costs. 3.106 It is important to note that the PIP does not Include the projects of churc-affliat grouos or other NGOs. In the area of health, a large number of these projects (such as SECADEV and BELACD for the church-affiliated groups, and MSF for the other NGOs) operate on principles very similar to those of bilateral and multilateral projects, and it would be useful to Identify them here. An analysis of NGO financing, while very useful, was not possible in light of data unavailability and the time allocated for the preparation of this report. However, as this sector is particularly important in Chad, further research is needed to assess its role, not only as a provider of services, but also as a source of financing. 4. Cost.Reor 3.107 The principle of free health care for all is losing ground in Chad, as in most other African countries. External donors, be they bilateral or multilateral, church-affiliated groups or other NGOs, are increasingly demanding counterpart funds as a complement to their assistance in the form of financial contributions from the population. Chad's experiences in this area go back some time, albeit on a small scale;9 the decree instituting a cost recovery system was enacted in October 1990. The system is, however, restricted to projects falling within the National PHC Program: (i) Health System Strengthening Program (EDF VI); (ii) Health System Support (MSP); (iiI) Child Survival in Chad (USAID); (iv) SDA Project (IDA); (v) Maternal and Child Health/Family Wellness; and (vi) Health Program in Chad (ITS); Primary Health Care Program (WHO-UNICEF). The type of payment adopted is that of a fixed charge for each episode of illness/risk at the first-level facilities and at the external referral centers. The hospital levels are excluded from this decree. Funds recovered will serve to replenish drug supplies and cover part of the operating expenditures (excluding wages). The proceeds will be deposited into an account in a commercial bank or at the Post Office. The health facilities, aided by a Management Committee, will be responsible for managing the funds recovered. 3.108 The process of setting up a cost recovery system in Chad is only starting: experiments are under way, but the individual approaches are often different. There does seem to be a consensus with respect to pricing: CFAF 400-500 for the "adult" rate and CFAF 200-250 for the "child" rate. The principle of cost recovery for non-traditional health services represents such a departure from custom both for patients and for health workers that time is needed to determine the system best suited to the country's economic and sociological conditions. However, the economic and financial data set forth above clearly show that an improvement in the health status of the Chadian population cannot come about without some financial participation by that population. Nevertheless, while the various actors intervening in the field must be allowed a certain autonomy to adapt to this particular environment, there is still a need to establish a general and coherent framework for the system finally adopted (Annx .2). 3.109 Conclusions. Two major conclusions may be derived from the above analysis: (a) Of the present per capita health expenditure of around US$5.5, low even by comparison with countries at a similar stage of development, 80% is financed by foreign assistance, covering three-fourths of the sector's actual operating expenditure. (b) The Plan d'Orientation of the Ministry of Planning and Cooperation clearly shows that the country intends to make health one of its top development priorities. Projections 4 Decree No. 102/MSP/SE/DG/90. -43 - show, however, that even with a planned substantial increase In the budget allocated to health (10% per annum), the Government will only manage to double its per capita health expenditure (from the present CFAF 364 to CFAP 747 In the year 2000). Thus, the Government also wants a continued and even intensified effort on the part of the foreign donors. Such a situation has significant consequences in that aid can no longer be regarded as a temporary replacement but as a necessary complement to the Government's limited resources. It is true that the ultimate goal of external donors must always be to prepare for their own withdrawal, in the case of Chad, premature withdrawal of donors will result In deterioration of the health system. Consequently, steps must be taken to ensure that any new foreign aid is granted for a sufficiently long term. -44- IV. mLoau=* A. Currnt Ntritional Situation 1. Introduion 4.01 The nutritional situation In Chad has been severely affected by several years of armed conflict, as well as two major droughts interspersed with years of poor rainfall. As a result, the emphasis of nutrition programs has been on emergency feeding and food aid distribution rather than preventive nutrition activities. Accurate data on the prevalence of chronic and severe malnutrition is virtually nonexistent, as available nutrition information tends to be short-term data gathering designed to determine food aid needs. Existing data do suggest, however, that malnutrition (<80% weight for height) Is highly prevalent among children 0-5 years old in many parts of Chad, especially during the rainy season prior to the harvest. The prevalence of malnutrition roughly follows a geographic pattern from north to south, with the lowest rates in the Sudanian southern provinces. Rates of severe malnutrition of 5-10% are routinely recorded in some rural areas even during years of "normal" rainfall, increasing to 15% and higher in years of drought or conflict0 n such as in 1984-85 and 1991. 4.02 While local food shortages clearly drive much of the malnutrition recorded in Chad, it should be noted that in years of normal rainfall, Chad is largely food self-sufficient. However, many households are food insecure. Most households sell a large portion of their crop soon after the harvest for cash needs. Moreover, poor distribution and transport links prevent grain from being efficiently shared between regions. To meet the needs in the Sahelian north, Chad depends heavily on food aid. On average, emergency food aid has represented some 15,000-20,000 tons,? increasing to over 60,000 tons in drought years. Food aid' averaged about 8% of total food production in 1970-1987, 59% of which was emergency aid. This is believed by some (although not documented) to have a disincentive effect on agricultural production and to be the reason for decreasing agricultural produce prices. 2. Food Consumption and Diet 4.03 Caloriake. Estimates of average caloric intake vary widely over time and by region. National data suggest average daily intakes of 1,660 calories, i.e., 75% of the recommended caloric requirement. One study in the southern Kanem region found an average daily intake of 2,100 to 2,900 calories per person per day which is higher than the national figure. The proportion of calories accounted for by proteins and lipids in this region, however, is lower than other national studies have suggested, and far lower than recommended levels. 4.04 Diet composition. The typical diet is comprised mostly of cereals in both urban and rural areas in Chad. In the Sahelian zone, millet, sorghum and rice are the staples, while in the Sudanian zone - Rapports d'Activiti des Equipes Mobiles, 1987, 1988, 1991. MAdecins Sans Front&res, Situation Midico-Nutritionnelle, 23 mal 1985. a UNDP, Human Development Report 1991, Oxford University Press (New York: 1991). Victor Lavy, "Alleviating Transitory Food Crises in Sub-Saharan Africa: International Altruism and Trade", World Bank Economic Review. Vol. 6, No. 1: pp. 125-138. .45- tubers and maize are eaten in addition to cereals. In rural areas, cereals are the principal source of energy, irrespective of the community's economic and agricultural activities. In the Kanem region, three villages studied depended on cereals for an average of 70% of their energy needs. These findings also suggest that annual cereal needs per person are as high as 200 kg per person in rural areas, rather than 135 kg as previously assumed (Ann IV1. 4.05 In urban areas, food consumption accounts for between 36% and 53% of total household expenditures, depending on socioeconomic status,' for an overall average of 44.8%. Cereals alone constitute almost one third of total food expenditures, or 14% overall. The remainder of food-related expenditures is accounted for by meat and fish (8.5%), condiments and oils (8.4%), cooking fuel and soap (4.9%), vegetables (4.5%), beverages (3.4%), and fruits (1.1%). 3. Prealence of Malnutrition 4.06 In general the occurrence of severe malnutrition coincides with the ecological zones. The worst conditions are usually in the Northern band of the Sahelian provinces, while rates of severe malnutrition in the South can be as low as 1% in normal years. This is by no means, however, a uniform pattern. Pockets of severe malnutrition have been detected in the South, often in areas with localized production problems caused by poor or exhausted soils, or an underemphasis on food crops over cash crops. The situation in the Sahel also varies widely between cantons, reflecting local differences in food production and distribution. There are also significant differences between the cities and rural areas. 4.07 Rural areas. Survey data of severe malnutrition vary widely, from 1% or 2% below 80% weight for height, to a high of 14% registered in November 1987 in one Kanem canton. Nevertheless, the incidence of malnutrition of children 12-36 months is consistently the highest," especially in the second year (12-24 months), reflecting the late introduction of weaning foods and the high incidence of diarrhea and various childhood infectious diseases. The statistical analysis of CNNTA survey data in N'DJamena shows a significant difference in rates of malnutrition between girls and boys, 10.2% and 7.5%, respectively. 4 In the context of the IDA-financed SDA Project (Cr. 2156-CD) and in collaboration with the Ministry of Plan's Direction des Statistiques, et des Etudes Economiques et Ddmographlques, a study of 300 households in N'Djamena was carried out during March-April 1988. * Equipes Mobiles CMVWA: 'Formation dans les Postes Sentineles (1987) and "Programme de Luae contre la Malntrition et les Carences Nwritonnelles (Prdsenatdon du Programme, mal 198). a -46- 4.08 Seasonal differences are extremely high, with the greatest stress occurring during the six months before the harvest. One survey carried out in the same community found 8.9% of children severely malnourished in July 1987, as compared to only 1.6% in January 1988" (Annex IV.2). 4.09 The prevalence of chronic, as opposed to severe, malnutrition among children is also believed to be high, although there are little data to support this conclusion. In Pala in July 1987, the CNNTA/Equ4pe Mobile found 34.3% of children below 80% of standard weight for age, of which 13.1% were below 70%. Using height for age, the CNNTA/University of Montreal study found rates of 13% below 85% of standard height In two areas of Kanem in March-April 1988. 4.10 Urban areas. Malnutrition is by no means confined to rural areas. Rates of severe malnutrition exceeding 10% have been found in some urban areas. Concerned by the high rate of malnutrition found in N'DJamena in 1987 (10.8%), the CNNTA undertook a more detailed survey in 1989 to identify the neighborhoods most severely affected for the targeting of nutrition interventions. High rates of severe malnutrition in all five districts of N'Djamena were found. In the Sahelian provinces, the urban surveys showed rates of urban malnutrition in some cases even greater than those in surveyed rural communities, possibly because grain must be purchased in cash, and because of the large proportion of formerly displaced peoples among those living in urban areas. 4.11 Nutrition-reated mortalt and morbidt. The 1989 N'Djamena Hospital records show that about 22% of admitted children were suffering from severe malnutrition as the primary cause of hospitalization. About 84% of those diagnosed suffered from marasmus, 9% from kwashiorkor, and 7% showed symptoms of both diseases. Malnutrition also represented the primary cause of death" of children 0-4 years old (31%). In 1985-86 the distribution of children by age revealed that 36% of malnourished children were under 12 months, while 44% were 13-24 months. Only 20% of reported cases were of children over 24 months of age. Moreover, 70% of hospitalized children enter with weight for height less than 80% of the NCHS standard. The seasonality of both nutrition-related mortality and morbidity is clear. In June through August, during the piriode de soudure before the harvest, the incidence of mortality is three to four times that of November to December. 4.12 Adulttritig. There is little information on the nutritional status of adults in Chad. Limited data on maternal nutritional status suggests that pregnant and lactating mothers have significant nutrition problems. More than 10% of mothers at N'Djamena Hospital gave birth to children weighing less than 2.5 kgs over a ten-week period in 1989, despite the fact that women who give birth in hospitals 5 Growth monitoring data collected by the CNNTA/Equipe Mobile are the most reliable source of nutrition information in Chad. Since it is an early warning system, the Equipe Mobile only visits areas where signs of severe malnutrition have been reported. The data are therefore not representative of Chad as a whole; still, they can be used to provide insight into seasonality and regional differences. " Severe malnutrition is defined by the CNNTA/Equipe Mobile as 80% weight for height using the NCHS standard (the source of anthropometric data in Chad). * MInistre de la Sant Publique, Direction de la Mddecine Hospitalthre et Urbaine, HZpial Central de N'djamina, Rapport d'Activt du Service de PdItrrie, Annde 1989. -47 - tend to have an above-average socioeconomic status. In Kanem, both men and women are well below the *optimal" body mass index," suggesting chronic malnutrition in the rural areas among adults. 4.13 Micro-urent deficiences. Vitamin A deficiency is widespread in Chad. In the upper Sahel, it is likely that over one-third of children and a significant number of adults suffer from Vitamin A deficiency. The same presumably applies to the BET and parts of the South as well. Widespread xerophthalmia among pregnant and lactating mothers is also found in Sahelian provinces. In Kanem in 1986, 32% of pregnant women were found to be suffering from hemeralopia, with 10% of hemeralopia cases showing signs of Bitot spots. Confirming the widespread nature of the problem, 70% of health centers in the region report hemeralopia as a problem, and there is a wealth of local names for the disease. A 1986 study of children near N'Djamena and two other provinces (Helen Keller International (HKI)) concluded that vitamin A deficiency is a "significant public health problem": 28.5% of the children were found to suffer from trachoma, 1.6% from night blindness, 0.9% with xerophthalmia, and 0.5 % with corneal scars. The prevalence of xerophthalmia was particularly alarming given that the survey was conducted at a time of relative food sufficiency and adequate nutritional status. 4.14 Data from four centers on women attending pre- and post-natal consultations show a high incidence of iron deficiency anemia,6 ranging from 25% to 63%. Rates for the population at large are probably even higher, as the sample was drawn from an urban and relatively well-off population in the Southern part of Chad. No data on other types of vitamin deficiencies have been gathered, but a prevalence of goiter from iodine deficiency in the Sudanian area is likely. This can be surmised on the basis of information on similar areas in adjacent countries, and from the dependence of the Southern diet on cassava. 4. Causes of Mai ton 4.15 The high incidence of malnutrition among children 12-24 months, and the seasonal and geographical distribution of severe malnutrition, have led to the common assumption that malnutrition in Chad is a result of two factors: poor weaning practices and food shortages. 4.16 At the community level, lack of access to food supplies does result in lower overall levels of nutritional status, as reflected by the variance in nutritional status and caloric intake in different ecological zones of the country. Yet, It is impossible to correlate malnutrition of individual children within a household with the overall food consumption of that household or community. The Centre National de NAridon et de Technologle Allmentaire (CNNTA)/University of Montreal study in Kanem, for example, found that malnutrition among infants can occur at similar levels regardless of household consumption levels. When households are classified by food consumption or energy consumption, no significant difference exists between households in the first quartile and those in the fourth. The only significant correlation found between household food consumption and child nutritional status was in the case of Vitamin A, where some reduction in avitaminosis is measured as household food consumption improves. 4.17 Malnutrition, especially among children 0-5 years of age, is a result of a number of interrelated factors. Increasing food availability at the community level may not be the only measure required to help vulnerable sub-groups within that population, especially when the lack of food is not the * Body mass index-weight (Kg)/height m. Ministare du Ddveloppement Rural/Mnsttre de 'Enseignement et de la Formation Professionnelle Agricole, Documents de projet etfiches Informatives diverses, 1989. -48 - primary cause of their illness. For example, inadequate supplies of food during the weaning period may be partly responsible for the high rates of malnutrition found in Chad among children 0-5 years of age. Yet other factors are equally or more important. These include: (a) abrupt weaning due to maternal pregnancy or cultural beliefs such as "bad" milk;' (b) late introduction of weaning foods; (c) inappropriate or poorly prepared weaning foods; (d) inadequate number of feeding times; and (e) poor bottle-feeding practices. All these causes are grouped together as mauvais sevrage, or poor weaning practices, but can be addressed only partially through increased food availability. 4.18 Other likely causes of malnutrition include lack of clean water, as well as poor sanitation and hygiene. These conditions lead to high rates of infection and especially diarrhea, one of the major killers of children in Chad. Since no studies have been carried out to determine the causes of malnutrition, It Is quite possible that there may be other factors in addition to those mentioned above. 5. Nutrition Information 4.19 There is a general lack of nutrition information at all levels. As a result, the targeting of programs to particularly vulnerable groups becomes difficult. It also makes the tracking of nutrition problems over time and the evaluation of nutrition interventions impossible. The CNNTA Equipe Mobile does provide anthropometric data in specific areas at risk to help orient emergency assistance. However, it lacks the capability to provide longitudinal data as well as to interpret qualitative data. B. Poies and Institutions 4.20 No comprehensive food and nutrition policy has been developed in Chad although a number of seminars' have been organized to help define a nutrition program. The lack of a coherent nutrition policy severely handicaps Chad's ability to address nutritional problems. Nutrition is accorded a low priority by government and donors alike. Donors who traditionally fund nutrition programs hesitate to do so in Chad, given the lack of a strong policy and institutional framework. 4.21 To the extent that nutrition is incorporated into government plans, the emphasis is almost entirely on curative rather than preventive activities. For example, the proposed paquet minimum d'activits (PMA) contains a nutrition component. But this component consists entirely of diagnosis of malnourished children for recuperation. It includes no preventive measures such as growth monitoring and nutrition education, nor the linkage of nutrition to other sectorial problems (sanitation, etc.). 4.22 The nutrition sector lacks a powerful coordinating unit. Activities are isolated and performed by various agencies and ministries with little knowledge of each other's actions. Lacking 6 Some ethnic groups believe that a mother's milk may be bitter or "bad" for the baby, and hence resulting in illness. To test for this condition, mothers place an ant into expressed milk. If the ant dies, the milk is considered unfit for the infant and breast- feeding stops abruptly. Alternatively, if the child develops thrush (a common ailment in children 0-6 months old), this is considered proof in itself that the mother's milk is "bad", and breast-feeding is immediately terminated. 2 These seminars include: SiMInalre de rdflexion sur les causes de la malnutrition et les possibilitis d'Interventions chez les e4fants de 0 & 5 ans (1989); Siminaire de programmation d'interventions nutritionnelles (1990); S&inaWire sur la stratigle de malnutrition (1990); Sfminare national sur les techniques et les mdthodes de prise en charge des malnaris (1991). -49- coherent direction, activities are almost entirely limited to food distribution In urban areas. Yet data have shown an overwhelming prevalence of chronic malnutrition in the isolated rural regions. The CNNTA is the Government organ currently responsible for the nutritional well-being for the entire population and Is currently designated as coordinating agency. With limited influence, technical capabilities and experienced staff, the CNNTA lacks leverage to promote cooperation with other ministries. Yet such cooperation is essential due to the integrated nature of nutrition problems. Despite its wide mandate as both an advocate and an implementing agency. The CNNTA has little influence over decisions affecting nutrition. There is no policy framework within which to operate, and its own role vis-h-vis other agencies is unclear. As a result, CNNTA is not respected by other ministerial or international agencies. Staff morale is low and motivation is lacking. 4.23 The new organizational chart for the MOPHSA also leaves several unanswered institutional questions. Within the institutional fusion of "social affairs" with "public health", it is unclear how the nutrition and PHC activities currently carried out in the Social Centers will be integrated into the rest of the Ministry's activities. Similarly, the responsibility for the supervision of the social affairs staff in those centers remains undetermined. C. Nutrltional Rgrm and Interentions 4.24 The ongoing nutrition programs are fragmented, reach a limited and largely urban population, and are almost exclusively curative in nature. Virtually all government nutrition interventions are carried out in cities through the social centers. Agencies that traditiona'0y promote preventive approaches to nutrition, such as WHO and UNICEF, are especially noticeable in their absence. 4.25 The range of activities undertaken by the CNNTA is too broad and goes beyond coordination to rehabilitation, and even food aid distribution. Such activities are stretching the finite resources of the center to the limit. Nutrition surveill is by far the most important and well established of all the activities performed by CNNTA. Results of the surveys have been quite instrumental in: (i) determining the prevalence of severe malnutrition in areas designated at risk; and (ii) recommending appropriate food aid levels based on the level and type of malnutrition found. Nuritio Rehabil is primarily done at the N'Djamena Central Hospital where the CNNTA runs a Nutrition, Education and Rehabilitation Center (CREN) in conjunction with the pediatric unit of the hospital. The center is primarily curative, offering food supplements. Like all Government-operated infrastructures in Chad, the CREN suffers from a lack of resources and poor management, thus influencing the quality of care rendered. Existing targeted nutrition programs, such as Vitamin A, iodine, ORT, etc., are highly vertical in implementation and tend to suffer from poor coordination and follow-up. 4.26 Despite the reorganization of MOPHSA and the planned integration of social centers activities into those of health facilities, the Department of Social Affairs continues to operate nutrition programs in 20 of its 22 social centers in urban areas throughout Chad. The centers, founded during the 1984-85 drought emergency by the then MOPH, offer porridge twice a day and dry rations during the weekend to severely malnourished children admitted into the program. Admission is based on nutritional status, measured by weight for height. Rudimentary nutrition education is offered and the children are weighed regularly. Growth monitoring charts are available in all the centers, but are reportedly not being used consitently. 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' . . . , �ц' ь�',л{� � •� . � �С�: � � . � ,и �� � г+tб. • ,о. : о . . • �� :.�� . • . • • Lo �. �,• гвг11__ �, �� • �.. . �• • 1"в� • �• �.. ��. ч : .�у ОО �'. � �( • � ' . . •} . ���+++ �. • • ч• �:�;'��: ':�.�•• � �::-••�• г ���� • ���{ • •�� �•��: • � • . . •г .. . :�. и г . • • . . . •�•f .��.. . -51- V- RFCMM=An= IN IWALUL POPULATION AND NEMRMON 5.01 Ile GOC needs to give precedence to: (a) Slowing the rapid pace of MW growth through stren population policies and programs, especially family planning, to enable, couples to space their children; (b) Improving the quality, coverage, and cost-effectiveness of health servic4es by: decentralizing the management and provision of health services to the provincial and district levels; and, strengthening the planning, management, and support/supervision capacity at the central level, and decentralized implementation capacity at the prefectural levels, to build upon the promising start made In the past, especially with regard to: - developing and applying protocols and standards of treatment; - manpower planning, career development, and pre- and in-service staff training; - management and distribution of drugs; infbmtion, education, and %Pa- ; and - control of key diseases, particularly AIDS. (c) Determining how to mobilize sufficient resources in order to support and sustain population, health and nutrition services while allowing fbr development needs and at the some time, decreasing Cbad's extreme dependency on external donors; and (d) Alleviating nutritional deficiencies and improving household food security measures through the development of a national nutrition policy and implementation mechanisms- maintenance of an institutional capacity to respond rapidly to emergency information needs; water supply and sanitation; agricultural support; and integration of health services aspects of nutrition into a basic package of health services. DetaHed recommendations are presented below for each topic. A. EgAng the Pace of NpUlation fitodh 1. XWdajhL E%ft 5.02 A coherent framework for the development of a cross-sectoral range of population and family planning activities in the country should be instituted. Accordingly, there is a need to: (a) Establish a national population commission to encourage cooperation and technical complementarities between government agencies, private sector and NGOs on population matters and to serve as the government coordinating body for the development of a population policy. (b) Strengthen the human resource base of MOPC to enable it to conduct the required multi- sectoral policy analysis and create within the Ministry a population unit to act as a -52- secretariat to the national population commission and to help coordinate policy develop- ment, strategies and program planning and implementation. 2. Famil Planning Servies 5.03 On the supply side, the potential for family planning program expansion within the existing public health facilities is quite substantial. Although some efforts are underway to accelerate service expansion through the network of MCH and PHC centers, progress is very slow in the absence of a well articulated MCHIFP strategy and plan of action and because of the inadequate logistics, monitoring and supervision systems. It is therefore necessary for the Government to undertake the following actions if the potential mentioned above is to be realized: (a) Develop a national family planning strategy and a multi-year plan of action and establish adequate implementation mechanisms for a phased introduction of PP services as part of the regular work of health personnel; (b) Strengthen management, administrative and technical capacity at central, regional and district levels for the full utilization of the existing facilities through the establishment of effective pre-service and in-service training programs for health providers and auxiliary personnel and improved logistics and supervision systems. 3. Informo Educat and ComM Aon Acti!itles (I 5.04 As FP service delivery programs are reinforced and expanded, greater emphasis should gradually be placed on activities which will help: (a) Expand awareness and generate adequate understanding of the population and develop- ment issues in order to build up support for population policy and program formulation; and, (b) Increase awareness of the benefits of family planning and knowledge of modern contraception, including sources of supply, among different segments of the population particularly men and young adults. 5.05 In order to achieve this shift, priority attention should be devoted to strengthening the capacity of the MOPHSA's health education unit to: (a) Design and coordinate the implementation of a comprehensive multi-media approach to IBC activities; and, (b) Mobilize existing resources of other ministries in the communications field and develop community and private sector/NGO participation in IEC activities on family plan- ning/family health matters. B. Improving the Ouaity. Coverage, and Cost-Effectiveness of Health Services 5.06 Chad has adopted the Primary Health Care strategy; it subscribes to the Initiative of Bamako with the implementation of cost recovery, and is in the process of applying the system of health districts. While Government's policies in the health sector are basically sound, attention needs to be directed towards their implementation. Over the last few years, the country has made very good progress in the planning and implementation of these policies. However, the problems are so immense and the -53 - Intervening groups so many, much more needs to be done to ensure quality, accessible and cost-effective health services. As mentioned briefly in para 5.01 (b) above, two fundamental issues need to be addressed: (a) how to decentralize the management and provision of health services; and, (b) how to strengthen the planning, management, and support/supervision capacity at the central level, and decentralized implementation capacity at the prefectural levels, to build upon the promising start made in the past. 1. Facilitating the Decentralization of Health Services 5.07 In its Plan d'Orientadon, the Government acknowledges that given the low accessibility of the majority of the population to health services, its objective is to provide basic health services to the largest number of people in the context of a three-tiered system (para 3.24) and a health redistricting plan (para 3.25). Fourteen prefectures have been created and the process of decentralizing their planning and management has been initiated. With the exception of two (Logone Oriental and Moyen Chari), each prefecture is being supported in this process by one or two donors (FED, FAC, MSF, IDA, etc.); this facilitates coordination and makes interventions more efficient. 5.08 According to the new organization chart of the MOPHSA, district authorities have the main responsibility to manage locally responsive PHC systems. As a result, they are in charge of defining and evaluating objectives for health services as well as for managing human and material resources in their districts. With the help of PERI and the BSPE, this process has been initiated in the nine prefectures of FED VI. A triennial health plan for every prefecture is being prepared, and general as well as specific objectives are being set.0 This will lead to a clear definition of roles and responsibilities at each level of the health pyramid and to the development of a minimum package of health services for every type of health facility. Health workers in a health facility would form a collective team reporting to the manager of the facility rather than to the coordinator of separate special programs such as TB, MCH, etc. 5.09 Clearly, due to the weak planning and managerial capacity of the districts, this process needs to be introduced progressively and phased carefully over time. It should start with districts that have demonstrated capability in managing PHC. These districts will be provided assistance by developing the capacity of health management staff in critical planning and management functions; ensuring supply systems for crucial inputs such as basic medicines; and reinforcing referral and supervisory functions at the higher levels. These districts should also be given technical support and training to develop an information base, particularly in health posts and health centers, concerning the health problems of their catchment populations. This should pave the way for district management to not only plan and adjust health services according to demand, but also to provide on-the-job training to health workers. 2. Strengtening Planning Capacity at the Central Level 5.10 Putting into place the newly-mandated organization of the MOPHSA is institutionally the most urgent action needed. It necessitates the immediate nomination of competent personnel in key e3 For more information see PERI, Canevas pour I'dlaboration d'ane planfication sanUiare am Ministare de la Santd Publique as Tchad", May 1990. .54 - positions. The positions of directors at the central level are particularly important in ensuring the proper execution of reforms in the sector. 5.11 Given the decentralization and devolution of responsibility to the peripheral level, the role of the central level is that of policymaking, national health planning, and control as well as resource allocation. One critical and unique role of the MOPHSA is to develop appropriate proIocols d standards both for preventive and curative care. These are clear, straightforward lists of steps a health worker will have to follow when faced with a health problem. It is recommended that these protocols be developed in collaboration with the voluntary sector and NGOs which provide a sizable proportion of health services, thus enabling efficient use of resources and facilitating collaboration and referrals in regions where both types of providers coexist. 5.12 The current manpwe situati presents serious challenges to the quantitative and qualitative strengthening of the country's health services. Rather than recruitment of large numbers of new personnel, Chad needs a massive, prolonged, well-coordinated and well-focused program of in- service training, in addition to improvements in the quality of basic training of health workers. In order to set training priorities and to strengthen the planning and implementation of its training programs, the MOPHSA needs to define the needs for health personnel, by type and level of training, in terms of the specific tasks which are to be carried out at each level of the system - including services to be provided by health workers in communities and homes. These tasks should be specifically defined, so as to permit task-based definitions of the roles of each type of worker at each level, all within the context of the new health coverage plan and of guidelines for its phased implementation. 5.13 Based on available information, the following recommendations are made: (a) Develop a health personnel study that will consider both qualitative and quantitative aspects of the present situation. Findings should lead to a Health Personnel Plan for the country. This study should give particular attention to: broad personnel policies; incentives to encourage deployment in remote areas; manpower needs by level of facility and based on the new organizational structure of the MOPHSA; and supervision needs including quality control which should serve as a good feedback into the training system. (b) Training, particularly in-service, should have high priority. With respect to basic training, the ENSPSS needs help in planning and improving its progiams and in strengthening its staff. Its curricula need to be revised within the framework of the National Health Development Plan. Methods for testing aptitude, knowledge and skills for incoming, enrolled, as well as graduating students need to be revised to ensure good quality training of health personnel. (c) The medical faculty should not continue to operate, or at least should not operate as planned. Chad should pursue a policy of overseas training for physicians and for certain highly-specialized health personnel. One option, within such a policy, would be to maintain in-country medical training for only the last year of training (or for a post- graduation year), to provide country-specific, community-needs focused training for Chadian physicians. Consideration could be given to the possibility of requiring (with the collaboration of foreign medical schools) that medical students trained overseas on government-arranged scholarships return to Chad for such training before they receive their actual medical degree or are licensed in any country; however, it is likely that the students would find ways around such a regulation. - 55 - 5.14 Improvement In the pharmaceutical s in Chad is possible through the attainment of the following objectives: (a) the shortage of drugs is remedied by making essential drugs available to the general population in generic form and at the best possible price; (b) the central level (Division of Pharmacy) is strengthened and allowed to play a leading role in policymaking and quality control; and (c) given the vast country and the numerous transport and communication difficulties, distribution is decentralized. These improvements and their impact will be dependent on the progressive Implementation of a cost recovery system based on actual experiences reported by the National Commission for Cost Recovery; and the clear definition of the role of the PHARMAT particularly vis-k-vis the voluntary sector. 5.15 Accordingly, the following recommendations are made: (a) Reorganize and strengthen the Division of Pharmacy at the MOPHSA to enable it to develop a National Drug Plan based on essential drugs, complete integration of projects, and revised coherent legislation; (b) Increase the national budget allocated to drugs and supplies in order to cover the needs of the country and to decrease its dependence on donors; this should be accompanied by less rigid administrative procedures; (c) Abolish the monopolistic nature of drug importation by the PHARMAT; and review its role in accordance with the Essential Drugs Program; (d) Revise legislation and the modalities of its application; (e) Strengthen the division of inspe..don and quality control; (f) Create a committee at the central level for the management of drugs that will include all sectors - public, private and voluntary - in order to ensure access of the total population to high quality drugs; (g) Given the need to decrease dependence on technical assistants, particular attention should be given to training, both in-service as well as pre-service training, in the following categories: pharmacists, pharmacy technicians, administrators, etc.; (h) Rehabilitate hospital pharmacies; and (i) Conduct a feasibility study to assess the relevance and the rate of return of local drug manufacturing, including tertiary production (like packaging). 5.16 IEC grorams are especially important in Chad where a number of easily preventable diseases continue to be a major cause of morbidity and mortality. Given scarce resources, coordination among various IEC activities Is of utmost importance. The IEC unit in the MOPHSA should be reinforced to develop its capacity in: (a) Problem identification and analysis; (b) Conceptualizing and formulating IEC strategies that will encourage active participation of concerned parties for MCH and in community mobilization; (c) Coordination and support to different health programs; and -56 - (d) Follow-up and evaluation of the whole set of IEC activities, with particular attention given to IEC activities within the school health program. 5.17 The GOC has elaborated a Medium-term AIDS Plan 1990-93 and an Action Plan for 1992 (para 3.21). The current and potential extent of the AIDS problem, combined with a weak health system, warrant the continuation, and even increase, of donor support in order to sustain AIDS activities and facilitate their integration into health activities at all levels of the health pyramid. IDA is planning to undertake a rapid assessment of HIV/STD prevalence in Sahelian countries; it is recommended that Chad be one of the countries assessed. 5.18 Interventions targeting key diseases will be done at the central (mainly IEC, centralized drug procurement activities) as well as the district levels. Given the geographical variations with respect to the prevalence of diseases, these interventions will differ from one district to another, a difference that will be reflected in the district health plan. For example, if well-prepared, a health plan and the resulting activities for a Southern district where diseases such as onchocerciasis and trypanosomiasis are prevalent, would be different from that of a district in the Sudanese region which is more vulnerable to malaria. Therefore, strengthening the planning and management capacity of the district and intermediate levels, in addition to the central level, should result in demand-driven, well-targeted health plans. Clearly, decentralization of planning and management should be accompanied by a decentralization of resources - personnel, material and financial. C. Mobilizini SuMdent Resources for the Sector and Increasing Cost-Effectiveness 5.19 The discrepancy between allocated and actual expenditures on material (para.3.95) may be explained by limited resources as well as delays caused by administrative problems. The exact nature of the delay can only be identified by a detailed study of the administrative process involved in the distiuin of funds.- 5.20 Chad's extreme dependency on external donors must be reduced (para. 3.96). This will require: (i) improved planning (including recurrent costs considerations) with a view to strengthening services at the primary level and reducing inappropriate use of hospitals; (ii) increased Government allocations to the sector; (iii) improved operations management including the review of the functions and current effectiveness of services at all levels, particularly the district hospitals and regional hospitals; and (iv) cost recovery. As many administrative problems are related to accounting and budgeting. a detailed investigation in the account. ir and budgetne procedures anlied in the MOPHSA is required. To improve the functioning of the MOPHSA, it appears indispensable that civil servants be trained in basic administrative tasks such as accounting, costing of projects, and financial planning. 5.21 Given the scarcity of central government budgetary resources and the unlikelihood of increasing allocations to the health sector, additional resources need to be raised to reduce dependency on external donors while, at the same time, preventing a further decline in the quality of services delivered, and even to improve service quality. This can be done through: (i) increased community participation and self-reliance (such as participation in building and maintaining health postas); and (ii) the introduction of a fee system. The fee system is actually in an experimental stage in several regions of Chad (para 3.111 and Annex 7); it has shown some positive results so far and needs to be introduced throughout the country. It is strongly recommended that the district authorities themselves be responsible for setting the scale for user fees and that a significant proportion of the revenues generated be retained and used by the relevant facility. In addition, the following issues need to be taken into account: -57 - (a) Before establishing a user fee system, ensure that existing resources are efficiently used; (b) Determine ways by which individuals' ability to pay can be assessed and accordingly, develop an exemption system; (c) Discourage people from bypassing the referral chain by setting, for example, higher fees at hospitals for services also provided in a nearby PHC facility; (d) Set exemptions for services that have large externalities (i.e., preventive care, immuniza- tions, family planning); (e) Retain funds at the local level and provide incentives for staff; and (t) Establish good accounting and monitoring systems, accompanied by relevant staff training. 5.22 This health financing system should help increase self-reliance at all levels of the system. However, it should not be considered a substitute for the Governments budgetary allocations but rather as a way to Increase responsiveness of health services to local demand and enhance the remuneration, motivation, and productivity of health staff. It is recommended that the GOC undertake a comprhensiv sty of helth financing on the basis of which it draws up a realistic financing plan for the health/social affairs sector. D. Alleviating Nutritlonal Decencies and Improving Household Food Security Measures 5.23 Recommendations fall into four basic areas: nutrition policy, institutional strengthening, nutrition programs, and nutrition information systems. 1. Nutrition PolI 5.24 Establishing a policy framework for nutrition in Chad should be the highest priority. Specifically, the Government and donor community should take the following measures: (a) Make the fight against malnutrition a national issue and an inter-ministerial priority at the Tabkl Ronde donor's conference scheduled for January 1993. (b) Establish a broad set of policy guidelines for fighting malnutrition in Chad. These guidelines could be based on the following six principles: (1) Malnutrition is a serious problem in Chad, especially in the rural areas and major towns. (ii) Malnutrition has a number of causes that are linked to a wide range of issues, such as access to food, health and sanitation, child-rearing practices, social problems, etc. It cannot be addressed in isolation. (iii) While short-term curative measures have a role to play, malnutrition must be fought primarily through preventive measures. These measures could range from providing "well-baby" clinics to improving girls' education. -58 - (iv) The main components of these measures are growth monitoring, nutrition education, and the linkage of nutrition programs to other sectors. (v) Since prevention involves influencing human behavior, nutrition programs are best carried out with and by the communities themselves. (vi) While nutrition policy needs to be set centrally, it can be executed by many different ministries and agencies. 2. Instittiol Strengthning 5.25 In order to ensure the implementation of an effective and dynamic nutrition program in Chad, It is essential that the institutions responsible for fighting malnutrition in the country be strengthened. The strengthening of the institutional framework for nutrition has three components: (a) Desigate a clear role for nutrition in the current government structure. A central agency should be assigned the coordination of nutrition activities. The role of the agency will be to strongly articulate and enable nutrition policy in each of the executing ministries, as well as to provide the framework within which discrete nutrition activities can be funded by donors. The government agency should be equipped with an experienced nutrition planner. The planner should have knowledge of the intersectoral nature of the nutrition problem, as well as the ability to influence policy at all levels. The agency should be led by an experienced, dynamic leader with the skills and stature to command respect and make the informal system work. While the CNNTA ostensibly plays this coordinating role, a careful assessment of its leadership abilities is needed. Such an agency should keep itself distinct from implementation. (b) Clarify the role of nutrition within the MOPHSA. In the new organization of MOPHSA, four different bodies have partial responsibility for implementing nutrition programs: the CNNTA, the SMI-BF-Nutrition department, the health centers, and social affairs. These roles need to be clarified, with a clear division of labor. One approach would be to limit the CNNTA to information gathering and training activities, and transfer supervision (not implementation) of nutrition rehabilitation and other activities to the SMI-BF-Nutrition department. This dq .tment would ensure that nutrition prevention is intograted into the health care delivery system. The nutrition activities of Social Affairs, i turn, could be integrated with those of the health facility (district soclo-sanitaire). Dire A responsibility would therefore fall under the local health authorities, but responsibil.ty for technical support and financing would come from SMI-BF-Nutrition. This could begin as soon as the new organizational structure is put into effect. (c) Move the institutions carrying out nutrition activities closer to the communities. The current lack of effective nutrition institutions can only be remedied over the longer term if they reach out to the community level where the most severe problems persist. A level of health activity below that of the health district consisting of trained community health workers is the only means by which preventive health and nutrition programs can reach the community level. Redeployment of health personnel out of N'Djamena to the rural areas where the problems are is necessary. -59- 3. Nutritims 5.26 Strenthen Nutrition ProrM . Specific recommendations to strengthen nutrition programs Include: (a) Increase awareness at the ministerial and donor levels of the severity of malnutrition problems in Chad, In orderto identify needs, define projects and channel resources within a coherent policy framework. (b) Train social assistants and nurses in appropriate nutrition education techniques. Particular emphasis must be placed on techniques to help encourage community participation and nutrition problem-solving. (c) Encourage nutrition demonstrations using local foods at centers close to the mothers' homes, especially at the village level and on the outskirts of major towns. These projects are most successful where communities support the activity themselves. Given staff shortages in the rural areas, special emphasis must be placed on partnerships with women's groups, village health committees and traditional birth attendants (TBA), helping to train them to train community women. (d) Intensify nutrition messages through IEC on breast-feeding and proper weaning practices, nutrition, hygiene and sanitation. (e) Intensify support to the Ministry of Rural Development's nutrition education programs at the village level, focussing on the effective instruction of trainers of all rural development staff who are in contact with village groups. The program, for example, is an excellent example of a grassroots, integrated approach to nutrition. The training of local counsellors who then train village volunteers is extremely cost-effective, and offers a preventive approach involving the entire community. It is particularly important to support and expand this initiative until a preventive PHC program is more broadly implemented in Chad. (f) Train and provide refresher courses for all relevant health personnel in growth monitoring, nutrition education and other related activities. Every attempt should be made to enhance the content and interest level of their work. Also, for mid-career nutritionists, regional institutions (e.g., B6nin) can be used for refresher training. (g) Promote the integration of nutrition programs into other existing programs, such as credit, women's activities, small-scale agriculture, etc. The production, preservation and consumption of dry season crops to improve nutritional status and food availability year- round could be encouraged through the Ministry of Rural Development. (h) Support the training of TBAs in the recognition, prevention and treatment of malnutrition. The TBA could be used as the focal point to get the communities to work together attacking the different root causes of malnutrition in their communities. 4. Nutrition Infmato 5.27 In order to meet the substantial needs for improved nutrition information in Chad, a comprehensive nutrition information strategy needs to be developed and adopted by the Government, in -60- concert with donors and NGOs active in this area. ' This strategy is essential not only to better target nutrition interventions to those most at risk, but also to assess and improve the nutritional impact of broader projects and programs. In the short- and medium-term, the following steps should be taken: (a) National standards for nutritional surveillance in Chad should be established. (b) Surveys should be carried out by the Equipe Mobile and the BSPE (soon to be decentralized), and possibly BIEP and DSEED, to identify the causes of malnutrition, micro-nutrient deficiency, the prevalence of malnutrition, and vulnerable groups other than the classic case of women and children. (c) Use the survey results to begin targeting the most vulnerable groups in the most vulnerable areas. (d) Establish pilot programs in areas with established village health committees and village health workers and TBAs. This could include the WHOIUNDP pilot program and the more effective NGO project areas. (e) Ensure that the BSPE is able to make use of information on growth monitoring charts. Regular publication of information drawn from the charts will, in turn, encourage the social assistants to use them more. (f) Maintain the institutional capability to respond rapidly to emergency information needs in distressed areas to determine the type and level of assistance required. This means ongoing financial and technical assistance to the Equipe Mobile in performing its current role. 5.28 Over the longer-term, a national nutrition surveillance system should be fully integrated into a community-based PHC program, in which accurate growth monitoring data is gathered and disseminated from the community level upwards to central government. 5.29 In light of its budgetary constraints, the GOC needs to evaluate the above-mentioned recommendations in terms of their costs, particularly the recurrent costs. They also need to be evaluated in light of the future donors' support. On that issue, preparation for a donors' Round Table, expected to take place early 1993, will be the forum for discussion of these priorities and for much needed coordination. Conclusion 5.30 Given the political, institutional, and resource constraints of the country, priorities need to be established. Certain actions can be Initiated immediately; others, such as policy formulation, need to begin now in order to lay the foundation for longer-term development; still others will need to be implemented over a longer time span. In the immediate term, (a) regarding Family Planning (FP), it would be best to focus on: (I) Strengthening the Government's capacity to spearhead and coordinate the development of a population policy and strategic planning for the establishment of an effective national FP program. -61- (ii) Improving access to contraceptive service in existing health facilities through Increased training in FP for service providers, particularly nurses and midwives, and through community development activities, better referral system, supervision and management and further integration with basic health care services. (iii) Expanding IEC programs and targeting activities to several audiences including men and young adults. (iv) Organizing private sector and NGO participation in the delivery of PP information services. (b) regarding health care improvements, it should be feasible to: (I) Continue the preparation of the Round Table and accordingly, finalize the National Health Development Plan, including the definition of approaches, objectives, priorities, and necessary resources for its execution; convene thereafter, the donors' Round Table; (Ii) Implement the newly mandated organization of the MOPHSA with key competent managers in place at all levels; devote particular attention to the clear definition of the role of the pharmaceutical sector ensuring administrative independence between the drug procurement agency and the policymaking pharmacy division of the MOPHSA; (iii) Complete the redistricting process and develop adequate protocols (guidelines) for patient care, including criteria that should be applied in determining what levels of the health system should handle various cases; accordingly, determine the resources and the training programs needed; (iv) Begin selective devolution of responsibility to districts that have demonstrated capability in managing PHC; provide assistance to those districts by: developing the capacity of health management staff in critical planning and management functions; ensuring supply systems for crucial inputs such as basic medicines; and reinforcing referral and supervisory functions at the higher-level facilities; and (v) Develop and disseminate improved IEC for preventive health and AIDS control. (c) regarding Improving the nutritional status of Chad's population, particularly children and reproductive-age women, it would be best to focus on: (1) A clear definition of the roles, with respect to nutritional activities, at various levels of the health system, as mandated by the new organization of the MOPHSA; (ii) Determining accordingly the resources and training programs needed; and (ill) Developing the capability to respond rapidly to emergency information needs in distressed areas. -62 - 5.31 The above-mentioned priorities should lay the foundation for a longer-term development of the sectors and will facilitate the attainment of the following: (a) Finalize the national ,ation Voicy and Ulan of with clearly defined allocation of responsibilities for Implementation; (b) Achieve an Integrated approach to PHC and a multisectoral approach to preventive health (recognize the interrelatedness of interventions in water supply and agriculture, for example, to preventive health); (c) Develop a national nutritional strategy which is based on the concept of decentralization of nutrition activities and on a multisectoral policy (gives enough importance to water supply and sanitation, the role of changing household practices); and (d) Extend improvements and successful (cost-effective) experiences to other areas of the country as they become accessible. 5.32 There are important linkages as well as differences among the population, health, and nutrition issues that the GOC has to deal with among the actions required. For example, better nutrition is vital for health; family planning is an important factor in improving maternal and child health. However, while implementing an enhanced child-spacing program can be done relatively quickly and at a modest cost, the strengthening needed in health involves substantial investments in facilities which is costly and requires a long time to complete. -63 - ANNEXRH-1 Popn~atian Repartiden by Sex ad Age Group 1970 1975 1985 1988 AgeGroup M F Total M F Total M F Total M F Total 0.4 177 185 562 319 325 644 413 415 828 443 445 888 5-9 238 254 492 252 262 514 339 347 686 364 372 736 10-14 217 235 452 232 247 479 286 295 581 307 316 623 15-19 189 204 393 212 229 440 240 250 490 257 268 525 20-24 162 176 338 181 197 378 220 233 453 235 250 485 25-29 138 150 289 155 1,687 323 196 213 409 210 229 439 30-34 117 127 244 130 143 273 165 182 347 178 195 373 35-39 97 108 205 108 121 229 139 154 293 149 165 314 40-44 80 90 170 90 101 191 115 129 244 124 138 262 45-49 84 75 139 73 84 157 94 107 201 100 116 216 50-54 50 62 112 57 69 126 74 89 163 79 96 175 55-59 39 49 88 43 55 98 57 71 128 61 76 137 60+ 62 95 157 71 107 178 97 141 238 104 151 255 Total 1,730 1,910 3,640 1,923 2,107 4,030 2,435 2,626 5,061 2,611 2,817 5,428 Sumary indientirs m A Structure 1970 1985 1990 rent aged under 5 yas 9.9 16.3 17.3 Percnt aged under 15 yearn 41.3 41.3 41.9 Percent aged 15-59 years 54.3 58.6 52.2 Perct aged60+ 4.3 4.7 5.8 -64- ANNE=(- Populatio by Type ot Residence, 1970-19M8 (in thousands) Type of Residenc 1970 % 1985 % 1988 1. Urban 406 11.2 1,160 22.9 1,435 26.4 2. Rural 3,234 88.8 3,901 77.1 3,993 73.6 Total 3,649 100.0 5,961 100.0, 5,428 100.0 Populaton Density by Geographie Area Arca Population Surace Density ______________(inhabitants) (kan2) (inh./km2) Saharian/desetio 109,000 600,350 0.2 Sahelian 2,708,000 553,590 4.9 Southen 2,611,000 130,060 20.1 Total 5,428,000 1,284,000 4.2 Project Sie and Groth of the Popadon Populaion size (in millions) F~rlity assumption 1990 2000 2010 2020 1. Contant fkrtility 5.68 7.38 9.86 13.40 2. Standard d~cline 5.67 7.41 9.72 12.30 3. Rapid doelne 5.68 6.92 7.87 8.83 Growth rate ____ 2000 2010 2020 1. conutant fertility 2.84 3.07 3.28 2. Standard decline 2.82 2.43 2.07 3. Rapid decline 1.42 1.14 1.07 -65- ANNEX I- Preied Populadon by Age Group (in milliou) 1990 2000 2010 2020 Aged < 15 years 1. Consamnt ferility 1.19 1.60 2.18 3.04 2. Standard declin 1.19 1.62 2.11 2.42 3. Rapid deolin 1.19 1.37 1.23 1.22 Aged 15-64 years 1. Constant fertility 1.52 1.91 2.50 3.36 2. Standard decline 1.52 1.93 2.50 3.40 3. Rapiddeclin. 1.52 1.91 2.45 2.86 Agd > 65 yas 1. Contant fertility 0.09 0.12 0.15 0.20 2. Standarddeclne 0.09 0.12 0.15 0.19 3. Rapid declin 0.09 0.12 0.15 0.20 Dependency raio 1. Consant fertility 83.60 89.20 91.90 94.80 2. Standard declne 83.60 89.90 88.80 76.40 3. Rapid declin 83.60 77.40 56.10 49.20 Ucaith Mapwr by Spe~ialty Sat-i St rre Year T~ Pwo Phys s u mid-wives 1988 3,918 138 86 40 1989 3,927 147 86 40 1990 5,129 164 159 101 FIGURE 1 PROBLEMES DE SANTE LES PLUS FREQUENTS ANNEE 1991 PROBLEMUS DISANTE FIEVRE 12.6 TOUX-15 DE JOURS 10.9 D./MUSC.ART./CEPH 9.3 DIARRHEE 8.4 TRAUMATISME 7.4 INFECTION DE LA PEAU 6.4 CONJONCTIVITE 4.5 OTITE MOY./ANGINE 3.9 DYSENTERIE 3.6 INFECTION URINAIRE 2.* 0 2 4 6 8 10 12 14 1611 POUiCENtGE DES NOUVEAUX CAS SCURCE : RAPPORTS MENSUELS D'ACTIVITES FIiGt�R1E 2 I-iEALTI t PROBLCII�S SLAS®1�AL УА[�tAT10NS YEAR 199® � � ® °�I-�OU5A1�D .... � �..«.++.....+....w.w�..ь...... еео:ё�ё si вевв ....................----_..�....»«.....�.» ♦еи ввSи и • ее _:овв::Zв и вiZiевиви 'еjев ови • ве иве ввв•е•е • вв�еевв вв еи=евеееаи •в�и ве�в и и• е=еи•и.ие=е е�у:�еи=хв= е и в� eee�Ys ео• еТе ви • • • ее • вии• веи евSе i л.Е2евеиевеиве �в9 _!� • и ввввввеие еиi еиввееееввие•е «.-.•........_. • �У® "'.."'�.""""""""".""°- • ���йiй�:еi��ëiig: ë::::ëiiio�йийii:ëëE::iieв ...°.^»--...--.•.. � Еев°в�:i�:iS:���ZiYiëйZ iëйe3ieë й: вi:iiii:i°:вв: �:ii. ..:i�:::i:Zsëвйi:ii:iii::йe:::iвi:o:iië �::ë::i:S ёit:::� ::'ii. еви•е•иии•ее.вв•в•••ввев• еввеевеиеееиеиее•ивевв иеи••:и. еииеевве►е•и•евев•ве••�.еви •.еи•в•в.•вв••ив•.вие •iввв••ви•и�. .• •вв.ви•вввв•е•вв••в•. •вв•. •е.еZев�вв�ив�ие .в 1 •L'е . •.••.•�иеле••е•.е••••.е е••• • 9!/9 I�ве��0 �.••в•.е••••ве.• ��в•ввве••и ••• •.•еввв•в•в. •в• .ьве•в.вееве•е•е•••е• � . .еввевв.•в•ввввв•. �� �„,�, . • • • . .' . �� �,�� �\ , г � i���ip�1 � � i •./• V � ® е 5 �,,.� .. .. / .. ... � %!� , ��� �! / � ® � / / .-i/� 1А1� Р� MADt AP1t i�AY 1UlVf 1U� AUG S1:P ОСТ NOY UCC �s�nл�r�.s � с®r�юиcтtvrns р �tA��� СО1!(ii�i � 1S DAYS • :: ��R � А и � 9i0URCC: lи�4)t�T�lLY �R1'S 01� АС1`11/1TbES - BSPL � о� � - N Page l of 4 NOMBRE DE CAS DE SIDA PAR AN 200 . .. . .......... ... ............ . 160 ............. ............ ............ .. ..... ... 100 ebut M ........... . .... . ............................. 50 2 0 1986 1987 1988 1989 1990 1991 Nombre de ca -s Cas Kini offtelros noelninl du TC.11^0. @ .�. il��:..� -�. Раgв Z of 4 OiSTttlцU'P20N ГЛR ЛСС L•Т РЛR SСХГ DCS СЛS �L SIAЛ ЛU TCtiЛO ��1 19�1 t .....�..п�впsеtаа..�..... , ......«... .r. ..... ! , ...........� •к•х»sвппп+-г•аяr�тпгд�....п»�r��......•.. . t лс�r•. i iтомм� t rr•.л�г�с i �w� s t�ь�.c: s i� 1 г: � 'rcrr„1. . о �~ А 4 0 t 00 = ' � -' � ( • i i f i � � .�i - 14 �f 1 � 01 � � 2� �� � ._._.. . i ,._.._- i 1 i - � .� 1� - 19 У 4 • t 08 t j I;t ! � �0 - 29 f Э8 �f бр f i А$ '� t i i i i 1 � зо - з9 г гi : ie � � з� � с• r s r � -� t �о - а� t оа t ог t � 1о , f--- i i i i ..�.. � � �,�n - 59 ; 03 ' � 0 j i. Q3 � У. ��в � . �... �о = � i а s � . � � ; : i � .. .. ...`..�..,._. ��•ss�,n яE,�r.itid = '3 г 89 j 1 i 1�:, ; i i t i « -�••м�rлтезsпsssгs�sз:sзssssзт�гпл-езззагазssагязвs:з�гs:ггrаsя�е�+аваs�гмппагаsr����. SERO SURVEILLANCE PAR SITES SENTINELLES PERIODE MARS DECEMBRE 1991. TCHAD HOLIBRE SERO POSITIF 20 15- 101 0 hrDJAMENA MOUNDOU SARH SITES SENTMELLES EM 15-24 ANS IM 25-39 ANS Il 40-44 ANS -71 - Page 4 of 4 TASLEAU DE SURVEILLANCE DU VIt DES POSTES SENTINELLES (MARS-DECEMBRE 1991) AU TCtAD /T.L,E & CODE SOUS-GROUPE TAILLE DE 'PREVArLrC COPRE.'PONDANT PERIODE SENTINELLE ECHANTILLON i INSTANTANNi S1 DE L'D I C Viti Mars Femmes encein- 04cembre 19911 tes . i G90 t Malades tuber- WAMENA 1 culeux 130 8,4% Donneurs de sang 250 1,6% mai Femmes encein r tesl 600 4,1%i •t Décembre 199h to 004l MOUNDOU 2 Malades tuber- 1 C. - culeux 91 9,8% z fDonneurs de ___ 1sang .200 31 jui±±Let r remmes encein-j r tes 197 -21 SARIt 3 j Le.;ambre 1991t Malades tuber- . g ;culeux g 27 11,1 ) g Donneurs de t sang 51 1,9ý Juillet Femmes encein- · tes 1 27 0l AD.CftE 4 Ddcembre Malades tuber- 1991 g culeux g 28 f 3,5 g * Donneurs de g sang 47 -e.. -, - meWU -72 - PTMIDE UCIO-SMITAM ADMINISTRATIM ET F~TIIS SCIO-SANITAIRES 0* D . * * * 0 * * e 0 * * e 0 * * * MINISTRE * * SECRETAIfl 0'ITAT* * 0.0. * * D.O.A. * NIV* * gER * . DIRECTICUS INSTITUTIIS * * CENTRALES NATICKALS * NIMl* DIETM IAN* INEiiAM* PRFCMLSPEETAK* * DIRECTIOS OPITAmu * * PRRFECT~fALS PREFECT~RJ * DIRECTIONS NHWITAUX * DISTAICTS DISTRICTS * * * NIVEU* REPSSLES 2~ o RESP. * PERIPM* 20118 0 RESP. (CENTRES 8.8.) * * * Addn1stration Formtions osco-Smnitares socio-smitaires 喲州觀v orsaui忽atiouaic&r七一ceutrai&vei& 蠡、〕 MOPH New Organizational Chart Prefecture Level man*~ molo-smilmimm ur"m amt~ Ø~T3t" jemmma tom W at~. lemri-rAL Zelsnicri r.430_~17. I ItGuss Dalic~ mi #w~ Dai amw-n~. tatum- i hi 0 馴口．日九權••曾O啊同此，•也么關頃二Ch•二化 ’震薯誅必 《響之）《7勵《9)！忽）《婪？）《寧） 兩嶼計”〕曲。 豳諶圖豳‘l&l 11華〕《華鳥電1忽） ‘才念1 115，】181·l•1 rg 奉馴卜 晌州嚇細戶口曲““閑戶瞭驢細••由留d，勵細喊加d戶州•州· 州州開細細．由d•叫陣矚‘齡•網由常ot卹開“神細論節。開•開‘ .76- ANNEX M!4 Page 4 of 4 FXMK31M OF MOFUSA DMFETORATES The DoiM Directorate General (Direction GbOrale AOInte) supervises and coordinates socio-health regions and ensures proper implementation of the regional health plan. It also serves as a liaison between the regions and the central directorates. 1. The DirectoraW for EMBLng and (Direction PIx4ficadon et Formation) is in CJM9e of: () social and health planning; (ii) developing the information system; and (iii) elaborating and implemeaft the ttaining policy and program. 2. 7he Do== f9i Eimcial and Admmistrative Affm and Material (Direction Affaires Adminisralim, FinanclOres et MaMrlel) is responsible for- (1) activities related to human resources management; H) material gmal, (M) management of financial resources; Civ) data processing; and (y) activities related to legislation. 3. The Dk2o= for SwM and Health Inftau (DirectionEtablissementsSocto- Sanitaires) oversees: (i) the classification of social and health rftastructures and the specification of their functions; (H) the elaboration of legislation, policy, norms and procedures relative to public and private facilities, medical technology, pharmacy, and biomedical research. 4. The Directorate fbr Halth Activ (Direction des Ad"& Sankaires) is in charge of: (1) programming health activities* (10 ensuring the integration of health program; OR) epidemiological surveillance ; the control of major endemic diseases; Cv) promoting MCH, Family Well-Being and Nutrition; (y) promoting environmental health and hyvene; (vi) developing school health and occupational medicine; and (vii) ensuring quality of care. S. The Directorate of Women in Dm]Qn (Direction de la promotion F&ninw) is responsible for: (i) the elaboration, planning and execution of a national policy with respect to the promotion and integration of women in the development process; and (ii) the elaboration of legislation in favor of women rights. 6. The Directorate of Social Affairs (Direction des 4ffbires Sockdes) oversees the- (i) promotion of social family well-being-, (H) elaboration of policy, norms, al procedures relative to day care, orphanages and idndergartens; (iii) planning of social action programs; and (iv) elaboration of policies, norms and procedures aimed at the reinsertion of the handicapped and community development. -77 - ANNEX II-5 HEALTH IQRMATON SEM The restructuring of the health information system was done on the following basis:' 1. priority was given to the development of a standardized routine reporting system for all health facilities in the country, both public and private. This was mandated by a ministerial decree;2 2. Three types of reports were instituted: a. an annual inventory of each health facility with information on personnel and equipment as well as data on community participation and estimates of the population covered by the facility; b. a monthly activity report with information on all activities petformed by the facility. Two different types of monthly reports were conceived - one for the PS and a different one for other primary health facilities. The primary health facility report provides information on: immunizations, child preventive care, delivery, follow-up of TB patients, and curative services. Similar informa- tion is reported by the PS with a more elaborate list of health problems, results of laboratory tests and data on hospitalization. c. a weekly telegram from the PS reporting on a few infectious diseases with epidemic characteristics that could require immediate action. 3. All reports are transmitted to the medical district officer who in turn transmits them to the BSPE. In order to ensure the quality of data collection, national and regional seminars have been conducted to familiarize the staff with the new system. Detailed instruction manuals have also been distributed to all health facilities with the BSPE and the Regional Medical Officers providing necessary supervision. * Lippeveld, Theo. 1987. Designing a MIS for Chad: A Challenge for Public Health Managers. Paper prepared for presentation of the 5th Conference of the World Federation of PH Associations in Mexico City, 23-24 March 1987, 2 Decree No. O2/IMSP/SE/DGIBSPEI87 ，網歸•，寫劍”“•，絲寫鱸•．細鏽”•革“&“• ·礬：寺 ’細”二平“娜“～嫵·叫“汕“州韌娜． .79- Annex ffl Page 2 of 3 Heaith Fadlities and Beds/Plam by 100,000 Inhabitants and Region Hospitalsi Dispensaries Region Medical Clinics Total Cenm infimnarles Beds/PlacS Batha 0.36 57 Blitine 0.58 3.48 16 Borkou-Ennedi-Tibesd 0.93 15.83 75 Char!-Barguirmi 0.25 5.80 159 N'Djamena 1 0.41 4.92 140 -Chari-Barpirmi rural 0.15 5.26 19 oc Guera 0.40 52 KânSn 0.31 5.25 60 Lac 0.40 4.82 10 Logone midental, 0.58 6.07 137 Ugone orienw 0.62 11.23 79 Mayo-Kebbi 0.75 5.26 79 moyon"cud 1.26 7.10 123 ound"âî 0.24 6.50 71 saimm 0.74 4.42 72 Tandjîle 0.92 9.30 72 Country as a whole 0.58 6.22 76 -80- ANNE L-6 Page 3 of 3 Health Facilities Conditions of Buildings, Water and Electrical Supply, and Communications Hospitls/ Medical Infirmaries Dispensaries Health Others' Total % of Health Facilities Centers Maternities Centers #31 #29 #257 #27 #19 #363 1. Building condition Very good 67.7 37.9 49.0 37.0 52.6 49.0 Good 25.8 44.8 28.8 51.9 31.6 31.7 Bad 6.5 17.2 18.7 11.1 15.8 16.8 Unknown 0.0 0.0 0.0 0.0 0.0 2.5 2. Water supply Water supplying Bldgs 93.5 44.8 48.2 70.4 78.9 55.1 Water supply at < 100 m 3.2 10.4 17.9 14.8 10.5 15.4 Water supply at > 100 m 3.2 44.8 29.2 14.8 10.5 26.2 Unknown 0.0 0.0 4.7 0.0 0.0 3.3 3. Supply of electricity 83.9 37.9 16.0 0.0 42.1 L3.7 of which:2 STEB 26.9 27.3 61.0 0.0 62.5 46.5 Generator 80.8 54.5 46.3 0.0 100.0 62.3 Solar plants 23.1 27.3 14.6 0.0 0.0 17.4 Unknown 0.0 0.0 7.3 0.0 0.0 3.5 4. Telephone 16.1 6.9 6.2 0.0 26.3 7.77 5. Radio equipment 41.9 13.8 5.4 0.0 5.3 8.8 Centers for handicapped, lepraies. Many electric power supplies can exist in the am sanitary building. 鳥鸛間j馳州州隨．合訪期閱唱 、啡 騙口”J膩離開隨糅間田〕r震圍口劉團偶讓田闐寫開網廖馴口•口開矓購口開 f .82- ANbM Q-§ Page 1 of 2 REALTR EXMOMEZE ADM M"C ~down of Govmmmt Budget (in ou~t CFAF mffions) Yoor P«W=d OP~ Auth~ A~ Aud~ A~ 1985 953 953 594 80 1986 968 968 305 85 1987 617 617 122 90 1988 701 701 181 91 1989 1,290 1,128 334 .152 1990 1,195 1,139 525 396 1991 1,827 NA 633 NA P~ ie^ E~Si of dm H" sww m WHO- PCO/ICO, ~a, 1~ 1992. Hedth in CFAF milli~ P«~ GOVOnm~ eapm~ 1,535 21.7 Ext~ aid Tota 5,541 78.3 OP~ 4,710 66.6 capitd 831 11.7 TarAL 7,0r76 100.0 P~ Jé=, Eo~ and f~ Andysis of R" &~ in WHO-PCO/ICO, Gemva, J~ 1992. - 83- ANN= II-8 Page 2 of 2 Goveranent Budget Distribution (In CFAF thousands) 1990 1991 1992 Personnel Operating Personnel Operating Personnel Operating Common personnel expenditures 15,000 25,282 14,000 Direction de Cabinet 18,420 26,870 28,080 Direction Gadrale 17,308 33,708 532 DAAF 243,454 453,407 377,758 482,867 0 625,500 Hosp. & Urban Med. Dept. 660,530 796,355 910,381 Sanitary Engineering Dept. 115,290 30,000 153,185 30,000 0 15,000 Studies and Vocational Training 25,848 2,500 35,808 2,500 10,256 2,500 Dept. SSP Dept. 10,644 7,032 20,932 Preventive Medicine Dept. 45,976 38,688 0 Phamacies Dept. 19,523 67,000 21,288 120,000 0 122,000 Social Affairs Dept. 128,093 272,035 274,258 Woman's Development 32,112 18,645 52,192 Direction ENSPSS 0 0 0 0 0 29,100 Subtotal 1, 332,198 552,907 1,806,654 635,368 1,842,235 794,100 Orand Total 1,885,105 2,442,022 2,636,335 -84- ANNE OI- Page 1 of 2 Caloric Intake FAO Minimum Estimate Daily Mao Chddra Nokou (National Requirementa 1984-86) Energy 2,913 2,713 2,093 1,660 2,200 (Calories) Structure of Enrgy Intake (%) Carbohydrates 73.0 72.0 75.0 68.3 - Proteins 11.0 10.0 9.0 12.7 10.0 Lipids 16.0 18.0 16.0 19.0 20.0 s : CNNTMA ivUd de Mon~éa, Summary of Resul, Dani~il Pabre, FAO Confufant, *Apc Abntara, NtI*OwIste Socau~ , November 1988; Sir Stanley Davidon .l. Hm a Nutri an D Londo: Chumfhif Livingstone, 1979. Av~rage Qnndu of Cereus Cosumed at the Time of Survey Mao Ch~edda Kokou Date of suvey March 1988 April 1988 July 1988 Pmary source of imome Rain-fed Dry season farming Date cultivation subsistece agriulure _ _ _ _ _ _ _ Calories supplied bycereals 77% 72% 65% Cerals consumed per person/day (g) 221 411 66 Millet 10 6 78 Sorghm 28 62 87 Rico 177 21 95 Maim 186 13 7 Whiat 622 513 333 Total cereal consumed Equivalet quantiy of coreal 227 187 122 consmed per personiyeur (kg) sojg: CNNTA/Universit~ de Montr~l, Summarm of Remults. Pham 1 October 1989. .85- MAN IM-2 Page 1 of 2 PreVale of Severe Maun In Selected Tows and Villages, 1986-91 % Prevalence of Severe Province Subdivision Date Malnutrition (<80% weight/ height) Chari-Baguirmi Bousso 12/88 1.9 Bousm 12/88 4.6 N'Djamena 5/87 10.8 N'Djamena 6/89 8.5 KaneM Mao 11/86 2.7 Mao 6/87 4.9 Cheddra 8187 5.2 Nokou 8/87 5.8 Mao 9/87 5.3 Nokou 11/87 14.0 Nokou 11/87 4.2 Mao 2/88 6.5 Moussoo 4/88 7.1 Nokeu 2/90 15.6 Nokou 4/91 16.7 Mao 4/91 19.4 Moussoro 4/91 18.9 %atha Djedds 12/86 4.1 Djedda 1/87 6.0 Mangalm 4/87 1.6 Ati 8/87 10.5 Ali 2/88 3.5 Oum Hadjer 2/88 2.7 Oum Hadjer 2/89 1.4 Ouaddai Abdch6 2/87 2.6 Abdoh6 3/88 3.4 Bouttail 1/91 5.1 од � � � � � �� � �� � � 4 � i-. �i • ^ (р � � � `�g � � � � � � � � � � � � � � � � � � � � � � � � � ' � , � � � � . � J М+ �.i W W Vi �O �° Ме W 1r F+ �+ 1✓ 1✓ � � � �а � � � � � а а а � � а � � � � а а а а а � .. ..е ,.. .а .. .. ... .. .. �е .а .� .. ,.. ... ... м � � ''"' � � ,�.' м � 1� � и ; es и .• ао и $ Ci ia � ;•� �► w ... �.а �о а► и а. ю и и 2R � и� р о i.т :� b. � Ьо о� b � ут ►.• ..• iл Ъо .� Ъ► i.г о о• b'о� �о � � .°+ . � �� ю � О М Social Indkaton ot Devel<>pm«4 1991.92 Chad smortgim i inom¥ sm&P 25.30 15.20 ratat sådb. unä of y~ Y~ 54~ uw- fluMmre 1390 srOGF HUNMAN RMURCES sbA ~ *udgre Ot~~ n under (MM a 1990) mmom .31 4ý19 5.68 49S TOW,", 14 an under 3 a I %of 4 464 .Pop. O.S 54.7 4'.' 15-64 54J 50.8 603 57.8 Age depentinco tmåt 0.80 0 0 lj3 or of! 300 5k162 påmtage in am % *(pop. &9 0 2.5 3 rernales per 100 målet C-et= Runi p" &t~ r= ammal % 2-6 2i 31 d= 9 2.0 63 8.1 sa 43 U4 3.2 Urban/rurg g~ diffär~ diffärence 4.8 7.2 3.8 16 5.9 2.4 Prj~ PO~ ' mmans - 7.42 669 39n 769 27.91 De~nanb *(~&don gr«* 11e4c 2, blM jw thou. pop. 45.3 44.3 43.7 45.9 29.4 29.5 Totäl f~ y nu 6.03 ý.93 5.96 6.46 lj72 3.74 Con~ 48PM~ Oo't'ws=ý*cla;".49 .2 Child (0-4) 1 wmaa (15-49) Urbeft per IW wam Rutal 0 - ~ M~tde death tate W thai p* 27.6 23.8 I&S Warn T" . p. 1 &536 9.7 8.5 gC . ratt per thou. hvå 183.0 142 9 24.1 60 49.5 Undef 5 motta *ty rate 0 166.8 166.6 79.5 Life CXPC~CY at overall yoett 3&4 40.i 47.0 50.6 62.1 65.3 Labor föret (15.64) f~ 3&0 41.8 49.2 514 W 67.9 Total labor förce 1.28 1.97 198 1,413 238 A&Acultum % 80 lädustry '2.2 2.8 4.9 Fernale 23.2 21 21.y 37.9 35.9 32.3 Fernalet per 100 Urban timber Rual pwjc~ nuv % O(k;« fom 34 37.- 34.8 41.0 44.62 4a6 11.5 14-5 30.0 25.6 Edueld~ atältuffint of 1~ f*~ yean cm~ w~ yean - - - Dum INATURALRESOURCES Area * dm sq. km l lm 1.2n 23.066 37.780 n765 MsnUutal land MJtsdMiC 3 371 37.5 X23 X3 4F9 Agiiculmral PI. per k= 7 a i 1 54 2% 66 and wo~ 149 t28 6.677 8~ 6.174 Defotemation r= -0.7 Jan -0.6 4.4 U Acem to sate w~ % 2&0 - 3&2 67.8 Urbeft 43.0 75.5 7&2 Rutal 23.0 24.1 ws 4&9 Popuh~ gmw& Want mortality Pr~ school wrollment > 4 cbed L4~