C, ~2 35g& Document of The World Bank FOR OFFICIAL USE ONLY MICROFICHE COPY Report No. 10146-GUA Report No. 10146-GUA Type: (SAR) COLL, XK / X31987 / I-5119/ LA3WR STAFF APPRAISAL REPORT GUYANA SIMAP/HEALTH, NUTRITION, WATER AND SANITATION PROJECT APRIL 2, 1992 Ru-man Resources Division Country Department III Latin America and the Caribbean Regional Office This document has a restricted distribution and may be ustd by recipients only in the perfonnance of their official duties. Its contents may nt otherwise he disclosed wihout World Bank authorization. CURRENCY EQUIVALENTS (as of November 1991) Currer.cy Unit - Guyana Dollar (G$) US$1.0 G$120.00 G$1.0 - US$0.00833 FISCAL YEAR January 1 - December 31 ABBREVIATIONS CIDA Canadian International Development Agency CFNI Caribbean Food and Nutrition Institute EEC European Economic Community EP Emergency Program EPI Expanded Program of Immunization ERP Economic Recovery Program ESF Economic and Social Fund GAHEF Guyana Agency for Health Sciences Education, Environment and Food Policy GDP Gross Domestic Product COG Government of Guyana GRO Guyana's General Registration Office GUYWA Guyana Water Authority GUYMINE Guyana Mining Enterprises Limited ICB International Competitive Bidding IDA International Development Association IDB Inter-American Development Bank IES Income and Expenditure Survey IMF International Monetary Fund IMR Infant Mortality Rate LSMS Living Standards Measurement Survey MCSA Ministry of Culture and Social Assistance MCSD Ministry of Culture and Social Development MDI Multiple Deprivation Index MMR Maternal Mortality Rate MOH Ministry of Health NCHS US National Center for Health Statistics NGO Non-governmental Organization PAHO Pan American Health Organization PFP Policy Framework Paper PPF Project Preparation Facility RDCs Regional Democratic Councils SA Sponsoring Agency SILWFC Sugar Industry Labor Welfare Fund Committee SIMAP Social Impact Amelioration Program and Agency TFR Total Fertility Rate UNICEF United Nations Children Fund WFP World Food Program FOR OFFICAL USE ONLY GUYANA SInAP/HEALTH. NUTRITION. AND VATER AND SANITATION PROJECT STAJY APPRAISAL REPORT Table of Contents Page No. BASIC DATA SHEET ............................. I ., . .... iv CREDIT AND PROJECT SUMMARY ............................, v I. NACROECONONIC SETTING . . .. .......... 1 II. TME SINAP AGENCY 2 Origins and Objectives. 2 Institutional Structure and Staffing. 3 Functions and Approach. 3 III. SOCIAL SECTORS. 4 Social Indicators. 4 Population. 4 Health 4 Nutrition 5 Sources of Data. 7 The Health Care System. 8 Water Supply and Sanitation 9 Water Supply ............ 9 Human Excreta Disposal .10 Stormwater Drainage .10 Sectoral Study and Master Plan 11 The Role of International Donor Agencies .11 IV. THE ROLE OF EGOs .12 V. WOMEN'S CONSIDERATIONS .,, 12 VI. RATIONALE FOR IDA INVOLVEM.ET 13 This report is based on the findings of preparation and appraisal missions that visited Guyana between December 1990 and October 1991. The missions were led by Xavier Coll (LA3HR) and comprised Julie Van Domelen (Consultant), Fernando Vio (Consultant), Gerardo Garrett (Swmmer Intern), Elene Makonnen (PHRWH)p Roy Ramani (LA3IE), Fernando Patiflo (Consultant), and Renata Claros (Consultant). The peer reviewers were Steen Jorgensen (AF6PH) and Julio Linares (EH2IE). M. V. Lister and S. Dy (LA30R) contributed to the preparation of the report. This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. - ii - page no, VII. tlf I J C .............................................................. 14 Objectives .................................................... 14 Summary Project Description ................................... 14 Detailed Project Description .................................. 15 Institutional Development Component ....................... 15 Sub-Project Implementation Component ...................... 16 LSMS Component ........................................... 18 Health Sector Policy Development Component .... ........... 18 Environmental Aspects .................................... 18 VIII. PROJECT I . . .......................................... 19 Institutional Arrangements ................................... 19 Implementation Arrangements ................ .. .................. 19 Promotion and Targeting .................................. 19 Sub-Project Appraisal ................................... 21 Sub-Project Implementation and Supervision .... .......... 23 Sector Coordination .................. I .................. 24 Information Management, Monitoring and Evaluation .... .... 24 Review by IDA ............................................ 25 -II. PRO_JECT COSTS. FINANCING, DISBURSEMENTS AND PROcREMET ....... 26 Project Costs ................................................. 26 Financing Plan I ............................................... 28 Cofinancing Arrangements ...................................... 28 Disbursements ................................................. 28 Accounts and Auditing .................... 29 Procurement ... .................... 29 Civil Works ............................................. 31 Goods .. 31 Consultants ............................................. 32 IDA's Review . ........................................... 32 X. §BL_FITS An RI ...........................,,,.... 33 Benefits ...................................................... 33 Risks ......................................................... 33 xI. AGREEMENTS REACHED MAD RECOMMENDATION ......................... 33 Agreements Reached ................. 33 Recommendation ................ . 35 - iii - LIST OF ANNEXES ANNEX 1: Official Order ANNE 2: Organizational Structure of SIMAP Agency ANNEX 3: Social Sectors ANNEX 4: Nutrition Programs ANNEX 5: Institutional Development Component: Technical Assistance ANNEX 6: Criteria for Sub-Project Eligibility ANNEX 7: SIMAP Framework for Phase-Out Plan ANNEX 8: Key Indicators of SIMAP's Management Information System ANNEX 9: Implementation Plan and Review Criteria ANNEX 10: Detailed Project Costs AMNEX l: Financing Plan ANNEX_ 12: Table 1 Disbursement Forecast Table 2 Disbursement Allocations ANNEX 13: Implementation Schedule ANNEX 14: Selected Documents and Data Available in the Project File MAP&: IBRD No. 11683R1 iv - GUYANA S8HAP/JHALTH. NUTRITION. M D WATER AND SANITATION PROJECT Basic Data Sheet DATA YEAR SOURCE A. GENERAL COUNTRY DATA: 1. Total Population (Million) (Estimated) 0.80 1989 SID 2. Population Projection (Million): 0.82 2000 SID 3. Size of Stationary Population (Million) 1.30 1989 SID 4. Urban Population 2 of Total 34.1 1989 SID 5. Area (1,000 Xm2) 215 1989 SID 6. Pop. Density (Per Km2) 4 1989 SID 7. GNP Per Capita (US$) 310 1989 IMP B. POPULATION DATA: 1. Crude Birth Rate (Per 1,000 Population) 25.6 1989 SID 2. Crude Death Rate (Per 1,000 Population) 7.6 1989 SID 3. Annual Rate of Population Growth (2) 0.1 1989 SID 4. Total Fe.tility Rate (Births Per Woman) 2.92 1989 SID 5. Population Age Structure (2 of Total): 14 and under 35.9 1989 SID 15-64 Years 59.2 1989 SID 6. Contraceptive Prevalence (2 Women 15-49) 29.0 1975 SID C. HEALTH DATA: 1. Population Per Physician (Persons) 6,220 1989 SID 2. Population Per Nurse (Persons) 885 1989 SID 3. Population Per Hospital Bed (Persons) 300 1989 SID 4. Health as Percentage of GDP 4.4 1987 UN 5. Health as Percentage of Total Govt. Expenditure 3.7 1984 IMp 6. Infant Mortality Rate (Per 1,000 live births) 53.2 1989 SID 7. Under 5 mortality Rate (Per 1,000 live births) 64.3 1989 SID 8. Life Expectancy at Birth (Years): Women 66.6 1989 SID Overall 63.7 1989 SID 9. Prevalence of malnutrition (under 5) 22.1 1989 SID B. NUTRITION DATA: 1. Daily Calorie Supply (Per Person) 2,373 19C-9 SID 2. Daily Protein supply (Grams Per Person) 59 1989 SID E. EDUCATION DATA: 1. Primary Education Enrollment Rate (Z): Total 90.0 1989 SID Female 99.0 1989 SID 2. Secondary Education enrollment Rate (2): Total 55.0 1989 SID Female 62.0 1989 SID 3. Tertiary and Higher Education Enrollment Rate (2) 8.0 1988 * 4. Total Education Expenditure as Share of Total Public Expenditures (2) 5.5 1988/89 IDB 5. Public Education Expenditures as Share of GDP 4.3 1988/89 ** 6. Illiteracy rate: Overall Z of Pop.(age 15+) 4.1 1989 SID 2 of Female (age 15+) 5.2 1989 SID 7. Pupil-teacher ratio: Primary 37 1989 SID Secondary 19 1989 SID 8. Pupils reaching grade 4 (Z of cohort) 94.0 1989 SID 9. Repeater rate: Primary 3.5 1989 SID SOURCES: Social Indicators of Development, 1990. Most recent eitimates (SID) Inter-American Development Bank, Health Care II Project, 1990 (IDB) United Nations, Statistical Yearbook for Latin America and the Caribbean (UN) International Monetary Fund, Government Finance Statistics Yearbook (IMP) * Access, Quality and Efficiency in Caribbean Education, June 1991 ** Ministry of Education, Guyana, 1990 GUYANA SINAPaHEALTH. NUTRITION. AND WATER AND SANITATION PROJFt CREDIT AND PROJECT SUMMARY Borrower: Governuent of Guyana (COG) Beneficiaries: Target groups in rural and urban poverty areas, in particular women in child bearing age and children under 5 years of age, to be reached through NGOs, grass roots organizations, and local governments. Amount: SDR 7.5 million (US$10.3 million equivalent) Terms: Standard IDA terms, with 40 years maturity Onlending Terms: The GOG will pass on the funds to SIMAP. SIMAP will finance sub-projects through NGOs, grass roots organizations and local governments on a grant basis. Proiect Obiectives and Description: The main objective of the proposed project will be to assist the GOG in cushioning the social costs of the adjustment process through the establishment of an effective mechanism aimed at addressing the basic needs of the population in a decentralized manner, such as through NGOs, community groups, and local government agencies. The project will aim to: (a) improve health and nutrition status over the short- term, in particular of pregnant and lactating women and children under five, through the financing of food supplementation programs, the rehabilitation and equipping of health care centers and day-care centers, and the rehabilitation of the water supply, sanitation and stormwater drainage structures; and (b) assist the GOG in the formulation of sustainable policies and programs in the social sectors over the medium-term. The proposed project will consist of four components: (a) institutional development; (b) sub-project implementation; (c) establishment of a living standards measurement survey (LSMS); and (d) development of a policy framework in the health sector. The institutional development component (16 percent of total costs) will complement the efforts by the Inter-American Development Bank (IDB) to assist the GOG in the development of administrative, management and operational procedures for the Social Impact Amelioration Program (SIMAP) Agency. Financing will be provided for technical assistance, administrative costs, vehicles and office technology. A dated plan of action to phase-out SIMAP and gradually integrate its activities into existing government agencies - vi - has been developed and will be implemented. SIMAT will be vested with administrative, technical and financial autonomy and will be responsible for appraising, approving, financing and monitoring sub-projects. The sub-project implementation component (78.5 percent of total costs) will primarily address the basic health, nutrition and water and sanitation needs of the groups most affected by the country's economic decline, and in particular of pregnant and lactating women and children under five years of age. Eligibility criteria developed during project preparation define the nature and scope of sub-projects to be implemented in this component. Financing will be provided for: (a) rehabilitation and equipping of primary health care facilities; (b) nutrition surveillance and education, and food distribution programs targeted at children and pregnant and lactating women; (c) construction, rehabilitation and equipping of day-care centers; (d) installation and rehabilitation of basic water supply facilities and sanitation systems, and extension and rehabilitation of small drainage systems; and (e) technical assistance to sponsoring agencies. Based on proposals received over the past twelve months, SIMAP has identified a portfolio of solid sub-projects to be financed during the first year of implementation of the proposed project. The LSMS component (2.5 percent of total costs) will entail the development of a household survey to assist the GOG in the evaluation of policies and programs, with a particular focus on the social sectors. The LSMS will be implemented in conjunction with an income and expenditure survey financed by the United Nations Development Program (UNDP) and will draw data from a third of its 7,000 household sample. Financing will be provided for technical assistance, operating expenditures, and equipment. The health sector golicy develogment component (3 percent of total costs) will include the financing of national and international technical assistance to help the GOG define medium-term policies and strategies for the health and nutrition sectors and, on that basis, design a portfolio of programs and projects for external financing. benefLts: The proposed project would help cushion the negative effects of adjustment, while at the same time improving the country's capacity to design, implement, and monitor health, nutrition, sanitation and other community-initiated programs. It would have direct effects on the nutritional status of about 150,000 women of child-bearing age, and of 80,000 children under five, and would provide associated services such as primary health care and basic sanitation. Results from the LSHS would provide not only a tool for evaluating the impact of SIMAP's activities, but would also contribute to further understanding of the extent and depth of poverty and its correlates. This, coupled with the implementation of the phase-out plan for SIMAP and the preparation of an investment plan in the health and nutrition sectors, would help the GOG in the development of sustainable medium-term policies and programs in the social sectors. vii - Risks: The project faces several risks: (a) that SIMAP may ,;&ccumb to political pressure and approve sub-projects that &,-e inconsistent with agreed selection criteria; (b) that SIMAP's credibility may be eroded as a result of a prolonged hiatus between its launching and the start of operations; and (c) that demand for health and nutrition projects may be limited by the lack of project implementation capacity of non-governmental organizations (NGOs) and grass roots organizations. These risks would be reduced by: *(a) the careful selection of technical staff, the development of well-defined operating procedures and project eligibility criteria, attention to institutional development, supported by frequent supervision, annual reviews and technical assistance; (b) the definition of a core pipeline of sub- projects from national and local government agencies, municipalities and international organizations in order for SIMAP to address some of the most obvious and urgent needs; and (c) the emphasis on promotion activities during the project preparation phase including the broadening of SIMAP's current promotion strategies beyond NGOs and grass roots organizations to include national and local government agencies. Estimated Proiect Costs: Local Foreign Total ------US$ Million----- A. SIMAP Sub-roiects Health & Nutrition 3.11 1.26 4.37 Day Care Centers 0.90 0.11 1.01 Water and Sanitation 1.89 1.71 3.60 Technical Assistance to Participating SAs 0 14 0.06 0.20 Subtotal 6.04 3.14 9.18 B. SIMAP Institutional Support Administration 0.80 0.05 0.85 Equip., Veh. & Maint. 0.03 0.24 0.27 Technical Assistance 0.34 0.41 0.75 Subtotal 1.17 0.70 1.87 C. LSMS & Morbidity Survey Salaries 0.08 0.00 0.08 Equipment 0.01 0.02 0.03 Operational Exp. 0.07 0.00 0.07 Technical Assistance 0.02 Q 0.10 0.12 Subtotal 0.18 0.12 0.30 D. Health Sector Policy Devpt. Technical Assistance 0.07 0.28 0.35 Subtotal 0.07 0.28 0.35 Total Project Costs -a/ 7.46 4.24 11.70 a/ Exclusive of taxes and duties, which are not applicable. Includes US$750,000 PPP. v viii - Pinancine ln 1JS Mllion PercenLa,e IDA 10.30 88.0 Government 0.53 4.5 Beneficiaries 0.57 4.9 IDB 030 2.6 Total Esttmated IDA Disbursements: IDA Fiscal Year L992 1993 1994 lI95 1996 --US$ million---------- Annual 0.75 2.15 2.80 2.75 1.85 Cumulative 0.75 2.90 5.70 8.45 10.30 Rate of Retur: Not applicable IBRD 11683Rl 9OiTM glJ1EALTH. NUTRITION. AMD WATER_AMID SMIITATION PROJECT I. M&CROECONOMIC ETTING i.1 Guyana's economic situation rapidly worsened in the 1975-87 period. Per capita GDP decreased by 25 percent between 1975 and 1983. Economic growth averaged only about one percent a year in 1984-87. Economic decline was associated with a sharp reduction in the terms of trade, underpricing and rationing of foreign exchange, falling international reserves, rapidly growing government deficits, and sharply increased levels of domestic and external public debt. Throughout most of the period 1981-87, Guyana's principal export commodities (bauxite, sugar and rice), accounting for about one quarter of GDP, encountered a number of technical, organizational and financial problems and adverse weather conditions. The resulting decline and subsequent stagnation of production was compounded by weak external demand and falling world market prices for these commodities, which account f^r about 80 percent of Guyana's merchandise export earnings. Reduced foreign exchange earnings cut into the country's capacity to import inputs needed for production purposes. 1.2 Public sector finances markedly deteriorated as a result of the steady erosion of the Central Government's revenue base. The public sector's overall deficit increased from 43 percent of GDP in 1981 to 52 percent in 1986 (in 1987, as a result of reforms in a number of public enterprises and the improvement of their financial position, the overall public sector deficit decreased to an equivalent of 36 percent of GDP). Guyana's external trade and payments situation remained extremely weak during 1981-87. The main source of financing of domestic deficits was the accumulation of external payment arrears as Guyana was unable to meet Its external payment obligations. 1.3 The economic problems of the past two decades have contributed to the deterioration of Guyana's basic public infrastructure. This deterioration is most critical in the power sector, sea defenses, water supply, drainage and irrigation systems, and transport. Health facilities and schools have also been affected by the lack of investment funds and, for the most part, are in a serious state of disrepair. An additional effect of the economic decline has been the emigration of a growing proportion of the better educated work force: it is estimated that in the 1981-86 period at least 32,000 persons left the country. Labor market problems reflect the combination of a high number of vacancies, growing rates of unemployment, decreasing real wages, the influx of, women into the labor force due to sharp declines in household incomes, and discouraged worker effects. 1.4 In an effort to address the problems confronting the economy, the Government, with the assistance of the International Monetary Fund (IMF) and the International Development Association (IDA), prepared in 1988 a Policy Framework Paper (PFP) based on the Government's Economic Recovery Program (ERP). The PFP outlined a package of economic recovery measures aimed at restoring economic growth, over the medium-term, through the elimination of internal and external imbalances, and the normalization of Guyana's financial -2- relations with external donors. The Government's ERP is being supported by an IMF Stand-by Arrangement and by an IDA-financed structural adjustment credit and a related technical assistance credit. 1.5 The Government remains committed to carrying out the economic ref45rm program initiated in 1989. Following two major devaluations of the Guyana dollar in April 1989 and June 1990, the official exchange rate was again adjusted in February 1991 to the level of the parallel market. At the same time, the Government has raised prices of essential items to allow for the pass-through of the effects of the devaluation, liberalized the trade regime considerably, and initiated a divestment program covering the bauxite, sugar, electric power, air transport and the telecommunication sectors, and a number of other public enterprises. 1.6 Together with the unification of the exchange rate, second tranche price increase requirements have increased the price of sugar, rice and petroleum by as much as 120 percent and are having a substantial impact on real wages and on the capacity of large segments of the population to cover their basic needs. In the medium- and long-term, the ERP will have a positive impact on stimulating the economy, increasing public sector productivity and raising living standards. In the short-term, however, temporary assistance is needed to cushion the -ocial costs of the adjustment process. II. THE SIMAP AGENCY Origins and Objecttivs 2.1 Government preparation for the Social Impact Amelioration Prograi- (SIMAP) began in early July 1988, when an agreement was reached on the substance of tht ERP and the need to execute a social program in tandem with it. As an initial step, an Emergency Program (EP) was set-up v-ider the authority of the Ministry of Culture and Social Assistance (MCSA), funded through the IMF-sponsored Guyana Support Group, to provide up to US$2 million of short-term relief in the form of supplementary income payments to: (a) old age pensioners and public assistance recipients; and (b) pregnant and lactating women, and children under the age of five. Disbursements, in particular for women and children, were hampered by operational problems. 2.2 In April 1989, the Inter-American Development Bank (IDB) identified the need to support SIMAP. This support was channeled through a Technical Assistance Loan which enabled four Guyanese to visit Bolivia and get a first- hand exposure to the Bolivian Emergency Social Fuid, and through a project advance to finance a group of consultants in charge of defining the role and structure of SIMAP. Consequently, the Government and the IDB agreed to create an autonomous SIMAP Agency through a 1990 Order under the Public Corporations Act (see Annex 1). SIMAP's role underwent a shift from its focus of channeling emergency income supplements for vulnerable groups to a project- driven focus. Since its creation, over 250 project proposals, mostly in infrastructure and social services, have been submitted to SIMAP. -3- Instituttonal Structure and Staff n 2.3 Under the 1990 Order, the Agency is headed by a six-member Board of Directors appointed by the MCSA (three members selected among the Ministries of Finance, Health, Education, Agriculture, and Public Works; one member selected from the private sector; one from local non-governmental organizations (NGOs); and one from the University of Guyana). An executive director has the exclusive authority to submit sub-projects to the Board for its approval. The day-to-day management of SIMAP is carried out by an operations manager. 2.4 The six-member Board was constituted in February 1991. Its activities in the past months have included the appointment of its chairman, the definition of the Board's internal rules and regulations, and the approval of sub-projects to be financed by IDA's Project Preparation Facility (para. 7.3) and IDB's Technical Assistance Loan, and by bilateral donors (European Economic Community and Canadian Government, most notably). In addition to the approval of sub-projects, the Board has responsibilities in defining and overseeing SIMAP's policies, reviewing and approving the annual budget and action plan, and appointing the executive director. 2.5 At present, SIMAP is operating with ten professional level staff and ten support staff (see organizational chart in Annex 2). This staff level is considered appropriate at this stage but would need to be expanded to carry out the proposed project. The major constraint to SIMAP's administrative and operational capacity is the Government's cap on salaries that prevents SIMAP from attracting and retaining qualified staff (para. 7.5). Fimctions and A2DroS_ch 2.6 The principal functions of the SIMAP Agency are: (a) targeting of the most vulnerable groups; (b) sub-project promotion; (c) sub-project evaluation; (d) sub-project approval; (e) contracting with beneficiary agencies; (f) disbursement of funds and tracking of their execution; (g) establishment of information systems to monitor and assess the impact of sub- project implementation; (h) administration and tracking of funds from financing agencies; and (i) guaranteeing compliance with procurement procedures agreed with the financing agencies. 2.7 Sectozal ministries have neither the budgetary nor implementation capacity or mechanisms in place to respond quickly and efficiently to the needs of the poor. While SIMAP would receive support from the ministries and government agencies, and closely coordinate its work at the local level, it has a comparative advantage in financing small, short-term, technically simple projects that can reach the intended beneficiaries in a more direct manner. SIMAP is also more likely to reach a wider and more diverse group of beneficiaries as a result of its flexibility to channel funds through a wide network of sponsoring agencies (SAs) that include local government, community groups, NGOs, churches, grass roots organizations and the private sector. -4- III. SOCIAL SECTORS Social Indicators Poeulation 3.1 Guyana's population, estimated at 800,000 in 1989, has been declining in recent years as a result of sustained emigration and a low birth rate (Table 1, Annex 3). Between 1960 and 1986, the population growth rate decreased steadily from 3.25 to 0.78 percent. It is estimated that during the 1981-86 period at least 32,000 persons left the country for permanent residence abroad, and the emigration trend has probably intensified in the past five years. The crude birth rate declined from 33.7 per 1,000 in 1970 to 25.6 per 1,000 in 1989. As a result, the population's age structure has dramatically changed. Between 1970 and 1986, the 0-14 age group fell sharply as a proportion of the population, from 47.1 to 36.8 percent (Table 2, Annex 3). The dependency ratio, however, remains high: in 1985, approximately 23 percent of the population were women of childbearing age (15-44 years), 13 percent were children under five, and 6 percent were over 60 years. 3.2 Eighty three percent of the population live in the narrow coastal plain (including Regions I,II,III,IV,V and VI) (Table 3, Annex 3), most of which is below sea level and accounts for most of the country's agricultural resources. The population's racial structure is divided between east indians (49.5 percent), africans (30.5 percent), mixed (14 percent), amerindians (5.5 percent), and other (0.5 percent). Only about a third of the population is urban of which 70 percent live in Georgetown (pop. 200,000), and the rest is distributed in Linden (pop. 50,000) and New Amsterdam (pop. 30,000). 3.3 Total fertility rate (TFR) was estimated at 2.9 in 1989, a level similar to Jamaica and Chile, indicating good levels of education and a moderately high prevalence in the use of modern contraceptive methods. Life expectancy at birth is relatively high (63.7 years in 1989) and compares well with countries in the region with much higher GDP per capita (i.e., Venezuela, 69 years; Brazil, 65 years; and Colombia, 68 years). Health 3.4 Until the early 1980s, Guyana's health indicators compared favorably with those of other countries in the region (Table 4, Annex 3). Economic decline has been accompanied by a deterioration in the provision of health services. As a result, the crude death rate increased from 7.1 per 1,000 in 1979 to 7.6 per 1,000 in 1986; the infant mortality rate (IMR) increased from 44.5 per 1,000 in 1984 to 49.0 per 1,000 in 1986; and the mortality rate of children one to four years of age increased from 3.4 per 1,000 in 1984 to 4.4 per 1,000 in 19861. X Most recent estimates, while not totally consistent with these figures in their order of magnitude, seem to Indicate an increase in Infant deaths from diarrheal dieease, respiratory disease, malnutrition and anemia. This increase is compatible with a deteriorating trend in health status. -5- Maternal mortality is also on the rise: between 1979 and 1984, the maternal mortality rate (MMR) increased from 0.4 to 0.6 per 1,000 live births, a 50 percent increase (national figures are not available for more recent periods, but recorded MMRs at Georgetown Hospital show an increase from 1.6 in 1984 to 2.7 in 1988). 3.5 Although data is incomplete, acute diarrheal disease and acute respiratory disease, often associated with malnutrition, are the leading causes of childhood mortality and morbidity (Table 5, Annex 3). Over 90 percent of all cases of gastroenteritis reported in the 1984-87 period occurred in children less than five years of age. Other diseases affecting children are malaria, measles2, and whooping cough. Most of these childhood diseases can be prevented through adequate immunization or treated with simple and effective measures (e.g., oral rehydration therapy). The major causes of maternal mortality are toxemia during pregnancy, and hemorrhage and sepsis during puerperium. Increased pre- and post- natal care (currently, less than a third of pregnant women receive pre-natal care) would greatly reduce maternal mortality. 3.6 The Government's failure to address the deteriorating health status is reflected in low immunization levels. Despite the initiation of the Expanded Program of Immunization (EPI) in 1985, immunization rates show little improvement: in 1988, less than 65 percent of all children were fully immunized against tuberculosis, polio, diphtheria, whopping cough and tetanus (Table 6, Annex 3). UNICEF and PAHO attribute the poor impact of EPI to the lack of equipment and supplies to support cold chain requirements as well as to shortages of trained and motivated staff. Nutrition 3.7 Protein-Ener _ Malnutrition. In 1984, the latest year for which cause- specific national epidemiological data is available, severe protein-energy malnutrition was the principal cause of death in infants, and the second cause of death in children 1-4 years. An analysis of the nutritional status of children attending maternal and child health clinics in 1987 (representing almost 60 percent of all children under five years of age) was carried out by the Caribbean Food and Nutrition Institute (CFNI), and indicates that the number of severely malnourished children under five had almost quadrupled since 19823. In 1987, about one quarter of all children seen in the survey presented some degree of malnutrition (Table 7, Annex 3). The available data reveals a deteriorating trend in the nutritional status of children with unacceptably high prevalence in specific areas -- in particular, in the peri-urban areas of Georgetown (East Bank Demerara) and Linden. 3.8 Another 1987 CFNI survey (in which birth weights of 27,016 children under five years of age were recorded) shows that about 17 percent of children under five years of age had low birth weights. This figure compares unfavorably 2 In 1987 alone, about 500 meaeles cases (resulting in 43 deaths) were officially identified nationwide. These deaths could have been easily prevented through adequate ilmunization. 3 However, the difference in classification methods of malnutrition between data from 1987 (NCHS/WHO Standard) and 1982-86 (Gomez Classification) limits the validity of such comparison. 6 with other countries in the region*: Jamaica (8 percent), Venezuela (9 percent), Brazil (8 percent), and Haiti (17 percent). Low birth weight (birth weight under 2,500 grams) is a good proxy indicator of nutritional status of the mother, as well as a good predictor of the nutritional status of infants. 3.9 Breastfeeding. A 1989 study5 shows that, while 95 percent of ali children were breastfed as neonates, only 18 percent were being exclusively breastfed after the first month of life, and only 5 percent after the second month of life (the recommended length of exclusive breastfeeding is four to six months). This is a disturbing figure considering that most of the water supply is contaminated, that fuel (for boiling water) is scarce, and that instant formula is too. expensive for most families. As a result of the early deprivation of the substantial nutritional and immunological benefits of breastmilk and the lack of safe water, the incidence of infectious diseases, diarrhea and malnutrition is on the rise. The targeting of pregnant and lactating women and weaning children should be a critical element of any health intervention in Guyana. 3.10 Anemia. Anemia is a persistent public health problem among all age groups and sexes. A 1982 study found that almost 75 percent of all pregnant women, 65 percent of lactating women, and almost half of all pre-school children had hemoglobin levels below the 11 g/dl stanuard . Statistics from the Ministry of Health (MOH) show that, in 1987, about 70 percent of women checked in health centers had lhemoglobin levels below the cut-off point (Table 8, Annex 3). Statistics of anemia in school-age children show a decline from 76 percent in 1981 to 61 percent in 1986, but the prevalence remains high (Table 9, Annex 3). 3.11 Nutrition Programs. The MOH, with support from CFNI, PAHO and UNICEF, has slowly initiated nutrition interventions as part of its maternal and child health programs. These interventions include nutrition surveillance, nutrition education, training of health personnel and information dissemination campaigns. In addition, the World Food Program (WFP) is providing support to the Ministry of Education in the implementation of a nationwide school feeding program. The program covers children attending nursery and primary school. At present, no supplementary feeding nor nutrition recovery program targeted at children under the age of three or at pregnant and lactating women is in place. Annex 4 contains a description of the most significant nutrition programs. 3.12 Food Policy. The National Food and Nutrition Council was re- established in May 1989 after it ceased to function for a number of years. The Council comprises membership from relevant ministries and agencies and serves as an advisory group to the Guyana Agency for Health Sciences Education, Environment and Food Policy (GAHEF) which has been given responsibility for the formulation World Bank. World Development Report, 1990 (1985 figures). 5 Baseline study carried out for the Unesco Guyana Nutrition Education Project. 6 A.A. Johnson, H.C. Latham, and D.A. Rol. The prevalence and the Etiology of Nutritional Anemia in Guyana. American Journal of Clinical Nutrition. 35: 1982, 0. 302. 7 Based on World Health Organization Standards. -7- and implementation of policies and programs in food and nutrition. GAHEF, in close cooperation with the Council, CFNI and PAHO prepared a comprehensive report in January 1991 whic'. provides the latest available information on the food and nutrition situation and formulates a broad national food and nutrition policy. 3.13 Among the key findings of the report are: (a) a deteriorating trend in nutritional status (despite the fact that a crude assessment of national food availability for 1984 revealed a sufficiency of energy, protein and fat); and (b) high levels of anemia, particularly among children and pregnant and lactating women. At the policy level, the report defines the following priority areas: (a) reduction in malnutrition in children under five years; and (b) reduction in the prevalence *. anemia, especially among children and pregnant and lactating women. 3.14 Crude estimates of national food availability indicate that sufficient food is available to meet domestic requirements. High food prices, however, limit food availability at the household level; particularly among the lower socioeconomic groups and the unemployed who have difficulty acquiring an adequate food supply to satisfy their nutrition requirements. The recent lifting of price controls on basic commodities has led to substantial price increases for commodities such as sugar, rice, salt, edible oil and margarine. Based on information from Georgetown markets9, the average cost per day to purchase products ne^essary to cover the minimum daily nutritional requirements of one person increased from G$33.4 (G$1,002/month) in January 1990 to G$69.8 (G$2,094/month) in March 1991. This represents an increase of more than a 100 percent in 14 months (in current G$). The average cost of food per person constitutes about 90 percent of the minimum salaryl°. Detailed information on food production, distribution and pricing is available in the project file. Sources of Data 3.15 The absence of reliable and up-to-date data to monitor social programs and to effectively support the activities under the ERP is of great concern to policy makers and planners in the country. The last income and expenditure survey was conducted over twenty years ago; the Government has not published a consumer price index since 1989; and data from the 1990 Population Census is not yet ready for release. In addition, vital statistics have not been consolidated since 1987. Recently, several initiatives of varying scope and coverage have been initiated to help meet Guyana's data needs. The most notable is a UNDP-funded Income and Expenditure Survey currently scheduled to begin in March 1992. A sample of 7,000 households has been drawn from the urban and rural population of all the ten regions in the counitry and four survey rounds are scheduled to be implemented. In the health sector, a joint effort by CFNI, PAHO and the MOH is aimed at improving data collection from clinic attendance. A UNDP consultant, in collaboration with the General Registration Office (GRO) is tabulating vital statistics data for the last three years. A A National Food and Nutrition Policy for the Cooperative Republic of Guyana. Draft Discussion Paper prepared by GAHEF with technical support from CFNI and PAHO; 1990. 9 GAHEF carries monthly surveys of prices of basic food staples. 10 The minimum salary was around G$2,300/month in March 1991. -8- The Health Care System 3.16 Structure. The public sector is the main provider of health services. The MOH and the decentralized regional health services operate 25 hospitals, 104 health centers and 65 health posts and stations accounting for 82 percent of the 2,933 hospital beds and the bulk of outpatient services (Table 10, Annex 3). In a recent drive towards public sector decentralization", the administration of health services was delegated to the ten regional governments. Regions are directly responsible for the operation of hospitals and ambulatory care services in their jurisdictions, but are subject to technical supervision by the MOH. The central level of the MOH is responsible for the operation of national hospitals, including the,Georgetown Hospital and four specialized long-term care hospitals for geriatrics, psychiatry, children rehabilitation and leprosy. Most of the public health sector facilities have been affected by the lack of investment funds over the last decade and are in a serious state of disrepair. 3.17 Health services are divided into five levels of care. Level I includes health posts, staffed by a community health worker, functioning at the grass roots community level. Level II comprises health centers staffed by medexes , health visitors 3, midwives, environmental health officers and assistant nurses. District hospitals, which exist in eight of the ten regions, represent the third level of care. Level IV comprises regional hospitals which exist in four of the regions and offers services in four basic specialties (medicine, surgery, obstetrics and pediatrics). The national referral hospital of Georgetown and the four specialized hospitals constitute Level V. 3.18 In addition to public sector facilities, there are five private hospitals, all in Georgetown, with a total of 343 beds. Most of the physicians in attendance are also employed by the Georgetown Hospital. Two of the private hospitals are operated by religious organizations and are subsidized by donations received from affiliated groups overseas. There is a significant but unquantified number of private clinics offering both general and specialized outpatient services. 3.19 Policy and Objectives. The 1980 constitution establishes health care as a right of all citizens and states that the public health care system is the primary responsible for providing universal health services. The 1970 National Health Plan is the only stated guideline for the sector. While a Policy Committee was set up to advise the MOH on the development of policies, its recommendations on sectoral goals and objectives are vague, and include: (a) the reduction of mortality and morbidity rates (especially maternal and child mortality); (b) the amelioration of nutritional status; and (c) the improvement of environmental conditions. This is to be accomplished by strengthening planning and management, decentralizing the administration of services, developing manpower and expanding service infrastructure. The Government is also actively seeking arrangements with the private sector for the management of public hospitals. In 1980, a new constitution was proclaimed which divided the country into ten regions and the capital city of Georgetown, and conferred the administration of health services to the regional governments. 12 Nurses trained in an 18-month program. Nurses trained in a 3-year program. -9- 3.20 Human Resources. Among the main constraints to the development of the health system is the short supply of health care personnel (Tables 11 and 12, Annex 3). Shortages are due primarily to low salaries, lack of training facilities and poor working conditions leading to high attrition rates and emigration. A case in point of the crisis affecting human resources in the health sector was the three- month general strike of nurses in 1990. Nurses were demanding a 30 percent salary increase"' and improved working conditions. In most cases, transportation costs to and from the work place exceed salaries. & 3.21 Financing. The financial problem faced by the health sector is as acute as the manpower problem, and closely related. The critical situation is anchored in the decline of Guyana's economy. According to IDB estimates, between 1980 and 1988, public expenditures in health declined by 36 percent in real terms'5. Cuts in health care expenditures have resulted in severe budgetary restrictions in capital expenditures. Virtually no funds have been made available in the past decade for purchase of medical equipment and construction or rehabilitation of infrastructure. 3.22 Coverage. As reflected in the low immunization levels, the most important sector issue facing Guyana's health system is the limited coverage of primary health care services. The negative effects of this situation are most critical in children over one year of age. A 1983 nationwide survey shows that, at most, 58 percent of children in the 1-2 age group and 27 percent in the 2-5 age group were seen at least once in a health facility (Table 13, Annex 3). Low coverage results from manpower shortages, high transportation costs, lack of outreach services and shortages of drugs and supplies. A major objective of the health sector should be to restore public confidence in health services, through improvements in their accessibility and their quality with a view to increase utilization to acceptable levels. Rater SuiWly and Sanitation 3.23 Since 1981, the environmental health sector has suffered serious set- backs as a result of lack of maintenance of and investment in the water supply, and the drainage and wastewater systems. As a consequence of this and the poor coverage and inadequate quality of health services, the incidence of infectious diseases is on the rise. For instance, according to IDB figures, in the period 1983-88, the reported cases of infectious hepatitis increased by 33 percent; those of typhoid fever, by 302 percent; and those of gastroenteritis, by 205 percent. Water Supply 3.24 According to Government estimates, the existing water supply system covers approximately 98 and 70 percent of the urban and rural population, respectively. However, this does not reflect the serious problems pervading the system. In rural areas, for instance, almost 70 percent of households do not receive a regular supply of water, despite the fact that a majority have the necessary infrastructure on their lots. Disinfection, such as chlorination, is rarely practiced outside the major urban systems. Diesel pumping stations, particularly in rural areas, are not operational for substantial amounts of time due 14 In 1991, the monthly salaries for nurses and physicians averaged about US$35 and US$80 respectively (the minimum wage is estimated at about US$19). 15 Inter-American Development Bank. Guyana. Socioeconomic Report; November 1990. - 10 to fuel price increases, lack of maintenance and unavailability of spare parts. As a result of shortages, pipes have been damaged as people break them in an attempt to obtain water. This, in turn, has caused contamination by allowing polluted water to flow back into the pipes. For instance, it is estimated that, in the Georgetown area, approximately 30 percent of water production is wasted through leakages in the distribution system and household service connections. As a result of heavy pumping, ground water subsidence problems have also been observed. HYMan Excrete Disposal 3.25 Georgetown is the only urban center that has a sewerage system serving approximately 37 percent of its population. The remaining urban areas are served by septic tanks or pit latrines and the rural areas use mainly pit latrines. The urban and rural population served by an adequate system of excreta disposal was estimated to be 90 and 80 percent, respectively, in 1985. Despite the high coverage, the status of many septic tanks and latrines is far from being satisfactory. Furthermore, the Georgetown Municipal Authority reckons that many sewer pipes are broken and that about 90 percent of the house sewer connections are cracked. At present, there is a lack of public sanitation blocks in markets and other congested commercial areas in urban areas. There is also a pressing need to install or rehabilitate latrines in schools and health facilities throughout the country. 3.26 The current legislative framework establishing institutions in the water and sanitation sector has developed in an ad hoc fashion over time. As a consequence, many institutions have emerged with overlapping and potentially conflicting roles and responsibilities. The Guyana Water Authority (GUYWA), established in 1972 under the MOH, is the agency responsible for policy coordination. The Regional Democratic Councils (RDCs) are responsible for the operation and maintenance of rural water and sanitation systems". The Georgetown Sewerage and Water Commission and the New Amsterdam Municipal Council provide services to their respective towns. The Sugar Industry Labor Welfare Fund Committee (SILWFC) and the Guyana Mining Enterprises Limited (GUYMINE) provide services free of charge in the sugar-producing states and towns, and in the bauxite-producing areas (Linden, Ituci and Bartica), respectively. In general, the lack of resources in the sector and inadequate tariff levels (in most instances water rates17 cover only about 30 percent of operating expenditures) preclude the appropriate operation and maintenance of the water supply and sanitation systems. Stormwater Drainage 3.27 Most of the extensive stormwater drainage system was constructed before independence, during the period of formation and consolidation of the urban areas. It was later extended following a moderate pattern of urban growth. Georgetown for example, has approximately 60 miles of main open channels. The operation of the drainage systems in the northern coastal plain, which lies below sea level at high tide, is mainly based on an adequate control of the water levels. This type of la The Local Democratic Organs Act of 1980 which constitutes a policy of administrative decentralization to the regional level vested the responsibility of operation and management of water sector facilities to the regional authoritlea- 17 There are seven different vater tariff regimes in the country, ranging from flat rate charges in the regions, to volumetric charges for the few metered supplies in parts of Georgetown, and to ratable values of property in most of Georgetown area. - 11 - operation requires a permanent maintenance of the drains to preserve their hydraulic capacity. 3.28 Over the years, several channels in urban areas have become points of discharge for wastewater and septic tank effluents, as well as dumping places for refuse. The generalized lack of maintenance has allowed the progressive deterioration of most channels and ancillary installations (e.g, sluices, culverts) by erosion or loss of their capacity through silting and outgrowth of plants. These conditions have created a permanent health hazard and periodic flooding of property and public places with negative effects on the housing stock and urban infrastructure. The municipal authorities are responsible for the construction, operation and maintenance of urban drainage systems. This duty falls normally under the works department which executes works by direct administration or contracting. In general, municipal authorities do not have the capacity to do proper operation and maintenance due to financial and staff constraints. Sectoral Study and Master Plan 3.29 A study by GUYWA (funded by the IDB) was undertaken in 1989 against a background of declining standards of water quality, increasing consumer dissatisfaction and an escalating threat to public health from contaminated water supplies. The study highlighted the development constraints of decentralization and underscored an immediate need to strengthen GUYWA to provide focus and direction to the sector. The study also recommends an assessment of the safe yields of the ground water aquifers, particularly along the coastal strip. Implementation of the institutional aspects of the study's recommendations is currently being discussed by Government. The second-phase of the study (1991-93) is geared to the preparation of a medium-term master plan for water supply, sewerage and drainage for the greater Georgetown area and to identifying investment needs in the regions. The proposed project would complement this initiative by serving the immediate need to direct scrrce investments in the sector on a priority basis and by targeting poor rural areas. The Role of International Donor Agencies 3.30 The health sector receives a relatively small share of the international assistance channelled to Guyana. According to a UNDP review of development cooperation, the health sector absorbed only 4 percent of total disbursements in foreign assistance in 1989. The IDB has been a primary financing source for the health sector. In 1978, it approved a US41C.9 million project to support prinary and secondary health care in areas outside Gnorgetown. Recently, it has initiated financing of a US$31 million project to rehabilitate the Georgetown Hospital, improve the supply of drugs and strengthen management of the HOH. PAHO and UNICEF, as agencies specialized in health, are providing support in terms of technical assistance and project financing in the areas of maternal and child health care, immunization and AIDS. The European Economic Community (EEC) is currently financing efforts in the control of malaria and AIDS. There is limaited on-going support for nutrition programs, apart from the school feeding program financed by the WFP. The Canadian International Development Agency (CIDA) is financing infrastructure and social sector sub-projects through a joint administrative effort by SIMAP and the Canadian Hunger Foundation, an international NGO. In general, efforts by international donors have not been able to reverse the decline in coverage and quality of health services or stabilize the nutritional status of the population. - 12 - IV. THE ROLE OF NGOa 4.1 What distinguishes Guyana from other countries in the region at a similar income level is the dearth of NGOs and their lack of experience in implementing development-oriented programs. Although there is no official register of NGOs, it has been estimated that about one hundred such organizations operate in the country, though this figure clearly overstates the number of solid, active organizations carrying out on-going programs. Most of these are religious, civic or professional associations. The more active NGOs with national coverage, like the Lions Club, Rotary Club and some church organizations, tend to focus on small-scale, charity- related social projects. There are only two international NGOs and a very limited number of development-oriented national NGOs providing basic health and nutrition services on aft on-going basis. Where programs exist, they are limited to a small geographical area (down to the level of a single health clinic) or tend to focus on a pecific health issue, such as malaria control or family planning. 4.2 This lack of an NGO presence is a result of government policies in the past. The general policy environment tended to reinforce a reliance on state or government-controlled cooperatives to address the basic needs of society to the detriment of local initiative. International NGOs were discouraged from establishing operations in Guyana. As the current Government moves to liberalize the economy and allows for a plurality of participants in the development process, a greater role for grass roots organizations is envisioned. Moreover, the current economic crisis is causing a drop in the quality and coverage of basic services which had been provided by the Government in the past. NOOs and other community organizations will be needed to fill this gap. V. WONEN'S CONSIDERATIONS 5.1 In 1990, a UNDP-financed survey identified the needs of women in twelve communities located outside the major cities. Potable water supply was considered to be a priority in two-thirds of the communities surveyed. The need for day-care centers was cited in 40 percent, and nursery schools in 30 percent of the communities. The survey did not cover nutrition or health care. Nevertheless, women expressed serious concerns about income generating activities, a concern which reflects a deteriorating economic situation where women feel unable to provide basic necessities, such as food, for their families. 5.2 SIMAP has identified women and children as groups particularly vulnerable to the social costs imposed by the structural adjustment process. There are an estimated 173,000 women of child-bearing age (15-44 years) which comprises the key target group for SIMAP sub-projects in health and nutrition. These sub-projects will provide nutritional supplements, improved primary health care services (including an expansion in coverage of pre- and post-natal care), and educational programs (for instance, to improve breastfeeding and weaning practices). Sub- projects in water supply and basic sanitation, while not targeted to women per se, will provide important benefits in improved access and quality, responding to one of the major development needs. The program will also provide financing to expand the coverage of day-care centers, delivering nutritional benefits to children while * 13 - supporting the activities of working women. This is of particular importance given the growing number of female-headed households. VI. RATIONAZL FOR IDA INVOLVEHKN- 6.1 IDA's country assistance strategy for Guyana is aimed at supporting the Government's on-going economic recovery efforts, including its efforts to mitigate the adverse social impact of the adjustment process. IDA's involvement is particularly critical at this juncture to arrest the spread of poverty and the further deterioration of physical facilities, while investing in human capital through targeted interventions aimed at improving the health and nutrition status of the poor. The proposed IDA project is consistent with the above strategy. An infusion of resources in social services, coupled with the strengthening of the Government's ability to formulate sustainable policies and programs, would improve the country's capacity to implement the difficult adjustment measures associated with the ERP, and would complement IDB's financing of SIMAP as well as proposed IDA operations supporting the bauxite and sugar sectors. The proposed project would also seek to develop the capacity of grass roots organizations, NGOs and local government to address the most urgent health needs of the population in a quick and efficient manner. IDA's support of SIMAP's activities over the short-term would be carried out in association with assistance to the Government to increase its capacity to deliver quality health and nutrition services over the medium-term. 6.2 Key lessons learned from previous Bank Group experience in the Caribbean region, and from the Emergency and Social Fund in Bolivia (ESF), have been incorporated into the design of the proposed project. First, small, less-developed countries in the Caribbean need intensive technical assistance, as is provided in this operation, to supplement the very limited administrative and technical manpower available for project implementation. This is even more critical when considering that highly qualified leadership and staff was essential to the success of the Bolivian ESF. Second, alleviation of poverty requires modification of the demand- driven format of social fund-type projects with greater direction and care in targeting investments and services to ensure that the neediest groups are benefitted and that their most urgent needs are addressed. The proposed project incorporates careful targeting of beneficiaries coupled with an explicit choice of the most relevant services to address the most urgent needs. Third, financing of investments must be coordinated with budgeting of funds to cover operating costs to ensure the flow of benefits from infrastructure investments. Sub-project eligibility and appraisal criteria in the proposed operation have been designed to address this matter. Fourth, a simplified procurement process can be successfully applied for small and widely dispersed sub-projects, provided an effective system for quality control supplies the necessary checks and balances. Fifth, social fund-type projects are supervision intensive for Bank Group staff. The proposed project, through the contract of a procurement auditor and technical assistance to guarantee sub-project quality and compliance with eligibility criteria, seeks to reduce IDA's supervision burden 5. 10 For instance, the Bolivia Emergency Social Fund (ESF) and Social Investment Fund (SIF) projects had, in FY91, supervision coefficients of 22 staff-weeks and 43 staff-weeks respectively (the average supervision coefficient for Bank Group projects is 11.5 staff-weeks). - 14 - VII. THE JI CT 7.1 The main objective of the proposed project will be to assist the Government in cushioning the social costs of the adjustment process through the establishment of an effective mechanism aimed at addressing the basic needs of the population in a decentralized manner, such as through NGOs, community groups, and local government agencies. The project will aim to: (a) improve health and nutrition status over the short-term, in particular of women and children, through the financing of food supplementation programs, the rehabilitation and equipping of health care centers and day-care centers, and the rehabilitation of the water supply, sanitation and stormwater drainage structures; and (b) assist the Government in the formulation of sustainable policies and programs in the social sectors over the medium-term. Summary Project Descrigtion 7.2 The proposed project will consist of four components: (a) institutional development; (b) sub-project implementation; (c) establishment of a living standards measurement survey (LSMS); and (d) health sector policy development. The institutional development component will complement the IDB's efforts to assist the Government in the development of administrative and management procedures, operating criteria for SIMAP and targeting mechanisms. Technical assistance will also be financed to carry out external evaluations of SIMAP's impact. SIMAP will be vested with administrative, technical and financial autonomy and will be responsible for appraising, approving, financing and monitoring sub-projects. The sub-nroiect implementation component will primarily address the basic health, nutrition, and water and sanitation needs of the groups most affected by the country's economic decline, and in particular of pregnant and lactating women and children under five years of age. Financing will be provided for: (a) rehabilitation and equipping of primary health care facilities; (b) nutrition surveillance and education, and food distribution programs targeted at children and pregnant and lactating women; (c) construction, rehabilitation and equipping of day-care centers; (d) installation and rehabilitation of basic water supply facilities and sanitation systems, and extension and rehabilitation of small drainage systems; and (e) technical assistance to sponsoring agencies. The LSMS component will entail the implementation of a household survey to assist Government in the evaluation and development of policies and programs, with a particular focus on the social sectors. The health sector policy develoRment componeng will include the financing of national and international technical assistance to define a medium- term policy and strategies for the health sector and, on that basis, design a portfolio of projects for external financing. 7.3 A Project Preparation Facility (PPF) of US$750,000 was approved by IDA in April 1991 to finance project preparation activities (including short- and long-term technical assistance), baseline data surveys (in particular a - 15 - morbidity/malnutrition survey and a health facilities survey) and pilot sub- projects. The financing of pilot sub-projects through the PPF is intended to allow SIMAP to finalize and refine its project cycle mechanisms, improve sub- project promotion strategies, and establish credibility among NGOs and grass roots organizations. In October 1991, most PPF activities were completed or in their initial phase of execution: vehicles and computer equipment had been procured; technical assistance for management information systems, preparation of the operations manual, water and drainage systems and nutrition had been carried out; and twenty one pilot sub-projects with a total cost of about US$500,000 equivalent were in the start-up phase. In addition, following delays in the arrival of anthropometric equipment, the baseline morbidity and malnutrition survey was underway. Detailed Pro3ect DescrlRtion Institutional Development Component (US$1.87 million equivalent) 7.4 This component will focus on building the institutional capacity of SIMAP and will put substantial emphasis on strengthening SIMAP's technical expertise to target beneficiaries, appraise sub-projects and monitor their execution, evaluate the reel impact of sub-projects on beneficiary groups, and maintain transparency in the disbursement of funds and in procurement activities. To this aim, the project will finance short- and long-term technical assistance. Specifically, SIMAP will require technical assistance to: (a) strengthen administrative and accounting systems; (b) expand and refine the management information system for internal monitoring of the sub- project cycle; (c) refine the poverty targeting methodology and update the data base; (d) review the soundness of the unit price data base; (e) assess overall operational procedures and, on that basis, formulate recommendations for changes in SIMAP's operations manual; (f) evaluate the implementation of food supplementation schemes; (g) audit the quality and soundness of sub-projects in execution; (h) assist in the implementation of SIMAP's phase-out plan; and (i) monitor and evaluate the impact of sub-projects. A total of 31 man-months of international technical assistance and 50 man-months of local technical assistance will be required to complete these tasks. In addition, SIMAP will contract an international procurement agent to carry out tendering activities and procurement audits of shopping and direct contracting activities (para. 9.8), and a private auditing firm to carry out external audits (para. 9.7). Annex 5 defines the technical assistance needs and budget for this component. Draft terms of reference were finalized during appraisal and are available in the project file. Vehicles and office technology equipment will also be financed under this component. 7.5 The proposed project will finance SIMAP's additional staff19, including one water/sanitary engineer, one civil engineer, two health/nutrition specialists, and three field officers. During the start-up phase of SIMAP, this staffing level will assure the technical capacity to evaluate and monitor sub-projects. Other SIMAP staff (including the Executive Director, the 19 SDA staff are not public sector employees and have short-tenm contracts that reflect the transitional nature of SIMAP. - 16 - Operations Manager and other project officers) will continue to be financed under IDB's Technical Assistance Loan, At the end of the first year of implementation, one or two additional positions will be necessary given the expected increase in the volume of sub-projects in execution. During negotiations, assurances were obtained that SIMAP i1ll be maintained fully staffed with qualified personnel during the life of the project. The Board of Directors of SIMAP has recently approved a new salary scale that will allow the Agency to attract and retain qualified staff. Prior to negotiations, the Government submitted to IDA the revised salary scale which was approved by the Ministry of Finance in September 1991. During negotiations the Government agreed on an additional increase of SIMAP salaries, and assurances were obtained that annual reviews of SIMAP salaries will be carried out to ensure that salaries remain competitive. A condition of credit effectiveness will be that the revised salary scale is implemented (para. 11.3 (a)). Sub-Project Implementation Component (US$9.18 million equivalent) 7.6 The following types of sub-projects will be eligible for financing under the proposed project (Annex 6 contains detailed eligibility criteria): (a) Primary Health Care and Nutrition (i) construction, expansion or rehabilitation of district hospitals (maternal and child health outpatient services only), health centers and health posts; (ii) furniture, equipment and supplies for district hospitals (maternal and child health outpatient services only), health centers and health posts; (iii) supplies and seed stocks of essential drugs for primary health care facilities; (iv) per diem and transportation costs for health outreach programs; (v) monthly take-home food supplements to all children 6 months to 2 years of age, malnourished children (moderate and severe malnutrition) from two to five years of age, and all pregnant and lactating women attending health clinics. Two basic foodstuffs (milk20 and rice) will be distributed. Food will be purchased weekly by the sponsoring agency from local qualified suppliers. Food distribution schemes will only be eligible for financing if closely linked with nutrition surveillance and education activities. (vi) nutrition surveillance activities; and 20 An evaluation study of the potential negative impact of milk distribution on breastfeeding will be carried ost at the end of the first aix months of project implementation (this will be coupled With an evaluation of suitable alternatives to milk in the distribution scheme). - 17 - (vii) nutrition education activities, including promotion of breast feeding. (b) Day-Care (i) construction, rehabilitation, expansion and equipping (including growth monitoring equipment) of day-care centers; (ii) construction, rehabilitation, expansitn and equipping of kitchens and dining rooms (or serving areas) and food storage areas; (iii) food supplements for all children under five years of age attending the day care center (beneficiary contributions should account for at least 50 percent of the value of the food); (iv) nutrition education for parents; and (v) early stimulation and education activities. (c) Water Supply and Sanitation (i) Water Supply: construction, expansion or rehabilitation of public water supply system (standpipes) or the extension of domicile water supply systems to provide a public water supply system; and rehabilitation and reinforcement of domicile water supply networks only for collectives of less than 5,000 inhabitants; (ii) Wastewater Sanitation: constructior. or rehabilitation of water and sanitation facilities for schools, markets and public toilets; and construction of pit latrines; and (iii) Stormwater Drainage: construction or rehabilitation of residential drainage systems in densely populated rural areas including the rehabilitation or replacement of associated structures such as culverts. (d) Technical Assistance to Participating SAs SIHAP will contract technical assistance for the preparation of sub- project proposals that are deemed of sufficient importance, particularly in sub-projects where the sponsoring agency does not have access to the expertise needed to carry out the final technical design work. In selected cases, technical assistance will also be contracted to assist in sub-project implementation. Primarily, technical assistance to the sponsoring agencies will be required in connection with the finalization of designs for, and technical supervision of, water and storm drainage schemes and health infrastructure. Technical assistance costs should not exceed three percent of sub-project costs. - 18 - LSMS Component (US$0.3 million equivalent) 7.7 This component will focus on improving the country's data collection capacity so as to better understand the extent of poverty and the determinants of living standards. To this effect the project will finance activities aimed at developing the methodology for an LSMS, carrying out the field work and analyzing the results. The LSMS will be implemented in conjunction with UNDP's Income an4 Expenditure Survey (IES) and will draw data from a third of IES's 7,000 households sample. Selected LSMS modules, with a particular focus on social sectors data, will be added to the IES in its second survey round. The proposed project will finance equipment (including computers and software), operational expenditures, and technical assistance (10 man-months international and salaries and per diem of interviewers and survey supervisors). It is expected that preparatory activities (development of a questionnaire, preparation of manuals) will be undertaken with funds from IDA's Technical Assistance Credit. Survey rounds for the LSMS will be undertaken on three separate occasions, the last one of which is expected to be finalized in mid-1993. Health Sector Policy Development Component (US$0.35 million equivalent) 7.8 To ensure sustainability of sub-project benefits, in particular in the health and nutrition sector, the proposed project will finance technical assistance 'A0 man-months international; 25 man-months local) to help the Government define medium-term policies and strategies in the health sector. Technical assistance will cover the following areas: (a) analysis of the epidemiological profile, access to and coverage of services and data gathering and management; (b) analysis of health infrastructure, maintenance systems, medical equipment, drugs and supplies and transportation; (c) analysis of health sector financing and expenditures; (d) analysis of organizational and staffing arrangements and management systems; (e) definition of health priorities and target groups; (f) definition of key investments in health sector infrastructure, maintenance guidelines, and arrangements to guarantee the efficient procurement and distribution of equipment, supplies and drugs; (g) definition of institutional, staffing and management arrangements in conformity with epidemiological priorities and with due regard to the country's constraints; (h) definition of health sector investment program and of associated fiscal and financial arrangements; and (i) definition of a portfolio of solid projects for external financing. 7.9 The proposed technical assistance will be carried out within the framework of SIHAP's phase-out plan (para. 8.2) and with a view to ensuring sustainability of SIMAP-financed activities. In particular, this component will aim to define the institutional and financial arrangements, manpower needs, and operational mechanisms for the development of the sector over the medium-term. 7.10 Environment8l Aspects. The proposed project does not pose significant environmental concerns. The safe disposal of hazardous medical waste in health facilities will be addressed through inclusion of guidelines and norms in sub- project eligibility and appraisal criteria. - 19 - VIII. PROJECT ZIAPLEMNTATION InstitutioniaLArrangaw=&Ł 8.1 SIMAP will have overall responsibility for the project, except for the health sector policy development component to be carried out by the MOH. The Borrower will pass on the proceeds of the credit in grant form under subsidiary contractual arrangements satisfactory to IDA, to be signed by the Borrower with SIMAP. It will be a condition of credit effectiveness that the contractual arrangement between the Borrower and SIMAP has been duly signed and ratified (para. 11.3 (b)). SIMAP's operations manual (including operational and organizational structure, sample multi-party contracts with sponsoring agencies, manuals for promotion, evaluation and approval of sub-projects, administration and information systems, and a methodology for targeting and impact evaluation) was reviewed by IDA during the appraisal mission. The operations manual has been finalized and approved by SIMAP's Board, and is satisfactory to IDA in form and in substance. 8.2 SIMAP's role as an emergency institution providing stop-gap financing for small-scale projects to assure essential investments in infrastructure and social services is only justifiable in the short-term and in conjunction with the economic adjustment process. SIMAP has a project-driven approach which is ill-suited to function itn the medium-term when efficient public sector policies will need to be develop'ed. To assure the sustainability of projects implemented by SIMAP and the transfer of SIMAP's experience to line ministries, it is critical that a dated plan of action to phase-out SIMAP be developed. Annex 7 contains the rationale and conceptual framework for the phasing-out of SIMAP. Prior to negotiations, the Government submitted to IDA a dated plan of action to phase-out SIMAP and gradually integrate its activities into existing government r agencies. During negotiations, assurances were obtained that the proposed phase-out plan will be implemented in accordance with the agreed objectives and time frame. Implo ontat ion hrannements Promotion and Targeting 8.3 SIMAP'S Promotion Strategy. The first step in the sub-project cycle involves stimulating demand from sponsoring agencies in order to generate a sufficient pipeline of sub-projects. These promotion efforts are the responsibility of the project officers and field officers. SIMAP has undertaken a campaign to inform sponsoring agencies of SIMAP's program and criteria for sub-project selection. Meetings with a wide range of institutions at the regional level are followed up by visits of SIMAP project officers to assist in completing the sub-project proposal forms. 8.4 SIMAP has adopted a complementary approach of promoting sub-project proposals from institutions with experience in specific types of projects and with the ability to channel solid sub-project proposals in the short-term. SIMAP has approached an international NGO to support and expand its on-going - 20 - program in malaria control, and encouraged GAHEF to design a pilot project in rural latrines that could be replicated and extended to a wide number of rural communities. 8.5 Despite these promotion efforts, SIMAP expects that, in some cases, poorer communities and weaker sponsoring agencies will find it difficult to translate needs into concrete project proposals. In such cases, SIMAP will finance technical assistance, including short-term contracts with private engineers and architects, to draw up the final designs needed for sub-project appraisal (para. 7.6 (d)). This will be particularly important in the design of water supply and drainage systems, and health infrastructure for poor, rural communities. 8.6 As a result of SIMAP's promotion strategies, about 250 sub-project proposals have been submitted to the Agency. Within the framework of the project list proposed for the Consultative Group Meeting of July 1991, substantial efforts have been made to identify sub-projects that comply with SIMAP's stated objectives and eligibility criteria. SIMAP has identified a portfolio of solid sub-projects to be implemented during the first year of execution of the proposed operation. Prior to negotiations, SIMAP submitted to IDA a list and profiles of sub-projects suitable for financing during the first year of implementation and were found to be acceptable to IDA. 8.7 Targeting of Beneficiaries. Prior to appraisal, each sub-project will be screened to guarantee that it addresses SIMAP's target beneficiaries. First, its geographical location will be evaluated against regional level poverty maps. These maps will allow SIMAP to determine target funding levels per region. Second, its specific location will be considered and evaluated against indicators available at the village level. To the extent possible, these indicators will be tailored to the type of sub-project (i.e., infant mortality rates will be used to prioritize health projects; nutrition projects will use malnutrition levels). The regional and village level indicators will steer SIMAP's promotional strategy to stimulate demand and assist SIMAP in determining priorities for the flow of sub-projects through the sub-project cycle. Third, during the appraisal phase visit, SIMAP staff will verify the level of need of the population and the fit between SIMAP's targeting criteria and intended beneficiaries. 8.8 To orient the poverty targeting strategy, SIMAP has received support from UNDP in developing a poverty targeting methodology. The UNDP-financed study, conducted in 1990 and updated in 1991, used all available information sources to assess the general level of poverty through the analysis of key indicators in health, education, housing and employment. The study generated a multiple deprivation index (MDI) at the village level. SIMAP is using this information to develop a needs-based ranking system which will assign an indicator of poverty to each sub-project. Further refinements to this data base have been possible with the incorporation of data from the PPF-financed Morbidity and Malnutrition Survey and from the updating of vital statistics undertaken by the GRO. Initial results of both efforts are expected at the - 21 - beginning of 1992. The Government's targeting capability will be further enhanced with the implementation of the LSMS. SIMAP's poverty targeting mechanisms and data base have been finalized and are satisfactory to IDA. sub-Proxect ADRELaLsq 8.9 Each sub-project which falls within established project categories of health, nutrition, water supply and sanitation, and serves the target *beneficiary population will then undergo an appraisal process. The SIMAP project officer will conduct a site visit to verify location, scale and beneficiary population. The officer will prepare an evaluation report summarizing the visit's findings. The report, including any supporting documents, will be presented for review to an internal panel comprised of key SIMAP professional staff. Finally, the sub-project will be submitted to the Board of Directors for its official approval. The appraisal process has three facets: technical, financial and institutional. 8.10 Technical Appraisal. The technical appraisal will review the following aspects: (a) that the sub-project proposal includes all the necessary components required for its implementation (e.g., that nutrition sub-projects include growth monitoring, or that the physical rehabilitation of a health center also considers the purchase or replacement of basic equipment and medical supplies); (b) that the sub-project proposal is consistent with sector policy and norms (e.g., that the food supplements considered in a nutrition project satisfy protein and calorie guidelines, or that engineering and construction standards are followed for infrastructure projects); (c) that the infrastructure, equipment and other inputs are consistent in scale and content with the proposed activities and benefits of the project; (d) that the implementation of the proposed sub-project is technically feasible (e.g., that in a nutrition sub-project the proposed mode of food distribution is consistent with local food availability and operational capacity of the health or day-care facility, or private distributor); and (e) that the necessary counterpart contributions from the sponsoring agency or the community are in place, or will be upon sub-project implementation (e.g., in rural latrine projects, that provisions for labor inputs from beneficiaries are agreed upon by the community, or, in sub-projects involving health and day-care services, that sufficient staff exists or will be contracted by the sponsoring agency to guarantee sub-project implementation). - 22 - 8.11 Einancial Aggraisa1. The financial appraisal of a sub-project proposal will first verify that the proposal contains only expenditure categories allowable for financing under SIMAP guidelines. SIMAP will then review unit costs and compare them with standard costs in its price data base. SIMAP has established an initial unit cost data base, which includes costs for food supplements, medical supplies, labor, infrastructure and other materials, and is being updated on a periodic basis (e.g., bi-weekly for food prices, monthly for other materials excluding medical supplies, and quarterly for medical supplies). This data is being expanded with information from GUYWA on equipment and materials for water e and sanitation sub-projects. The price data base has been finalized and is acceptable to IDA. During negotiations, atisurances were obtained that SIMAP shall maintain at all times a reference price data base satisfactory to IDA. 8.12 Institutional Appraisal. The institutional appraisal process will assess the sponsoring agency's capacity to manage sub-project implementation and to assure that potential benefits are realized. To gauge institutional capacity, SIMAP will review: (a) the experience of the sponsoring agency in the community or general geographic area of the sub-project; (b) the experience of the sponsoring agency in implementing similar types of projects; (c) the history, legal status, and quality of personnel of the sponsoring agency; (d) criteria and methodology used to select beneficiaries; and (e) the forms and degree of participation in sub-project identification, preparation and implementation of the community in general and of target beneficiaries in particular. 8.13 Sub-Project Sustainability. Two major project components, health sector policy development and implementation of the LSMS, are designed with a view to ensuring sustainability of SIMAP benefits over the medium-term. This, coupled with the implementation of the plan to phase-out SIMAP and define the transfer mechanisms of SIMAP activities and responsibilities to line ministries and agencies, will assist the Government in the development of a solid investment program in the health sector once SIMAP's stop-gap financing ends. In addition, each individual sub-project will be appraised for continuity of its benefits after the phase-out of SIMAP. In water and sanitation sub-projects, SIMAP will ensure that institutional responsibility for collection of user fees and the operation and maintenance of these systems is clearly defined. SIMAP will also review arrangements for training beneficiaries to operate and maintain lower-technology water and sanitation systems. For projects in primary health care, SIMAP will assess the commitment of central, regional, and local governments or NGOs to finance the long-term recurrent costs of these services. It is assumed that the MOH, with funding from IDB's Health Care II Project, will address problems in the supply - 23 - of essential drugs and medical supplies in the medium-term, with SIMAP responding to emergency shortfalls over the next three years. 8.14 It will be more difficult to ensure sustainability of nutrition supplement programs given the limited operating budget that most sponsoring agencies have at present. Due to the importance of realizing a measurable impact on nutritional status, SIMAP will offer three years of renewed financing for sub-projects with a feeding component, with an annual performance review to justify annual extensions. At the end of four years of project implementation, a follow-up to the Morbidity and Malnutrition Survey will be carried out to assess the impact of the program on nutritional status. Concurrently, and as part of SIMAP's phase-out plan and the implementation of the health sector policy development component, the Government will review ongoing programs and existing institutional capacity and, on that basis, formulate a medium-term plan for the nutrition sector. During negotiations, it was agreed that the Government will issue, not later than December 31, 1993, a nutrition policy statement defining policies and programs designed to meet the nutritional needs of pregnant and lactating women and children under the age of five over the medium-term; and to start the execution of a specific plan of action to put into effect such policies and programs according to a timetable satisfactory to IDA. Sub-Project Implementation and Supervision 8.15 Sub-Project Implementation. Upon approval of a sub-project, a multi-party contract will be signed between SIMAP, the sponsoring agency and the selected contractor (where appropriate). In the case of infrastructure sub-projects where civil works are executed by a private contractor, performance guarantees will be sought, including performance bonds. In cases where guarantees can not be obtained (because of the size of the contractor), tranching of payments will be carried out where advances will be made against a well defined program. As a further assurance of quality execution, SIMAP will withhold five percent of each infrastructure contract during a specified period to insure against defects and liabilities. 8.16 Prior to the initiation of sub-project execution, the sponsoring agency will participate in a briefing by SIMAP on the general requirements of sub-project implementation, including accounting and record keeping, procurement, supervision arrangements, and disbursement systems. Disbursements will be made in tranches, according to progress in implementation. SIMAP project officers will undertake the monitoring of sub- project implementation to ensure that all activities proposed and appraised are carried out within schedule and that disbursements are in line with expenditures incurred in sub-project execution. This progress will be verified by site visits from SIMAP project officers, and confirmed by the supervisor (para. 8.17). 8.17 Supervision. While SIMAP project officers will provide important oversight of the project implementation process, they will not have the capacity to provide on-going technical supervision given the geographical dispersion and number of sub-projects. Therefore, to assure quality in the execution of sub-projects, SIMAP will contract external supervisors for sub- projects that are of sufficient scale or technical complexity or, by their - 24 - nature, require more intense technical supervision. For instance, in almost all civil works contracts, SIMAP will finance a site supervisor who will be responsible for co-signing the verification of works reports submitted by SIMAP project officers. The cost of external supervision and of technical assistance to support sponsoring agencies in the finalization of sub-project proposals (para. 7.6 (d)) will be included in the total sub-project costs, and will not exceed three percent of these costs. SIMAP will enter into a separate contract involving SIMAP, the sponsoring agency and the supervisor. In cases of specialized civil works, such as water and sanitation systems, SIMAP will use consulting engineering firms to carry out technical supervision in the field. For health and nutrition projects, the framework for supervision will vary according to the needs of the sub-projects. SIMAP will have an on-going technical supervision contract with GAHEF to spot-check the quality of the entire portfolio of SIMAP nutrition sub-projects. In addition, for sub-projects that include the distribution of food through health centers, an independent local community leader or organization could be appointed to verify the quality of the program on an on-going basis. Sector Coordination 8.18 SIMAP will function autonomously from line ministries and other governmental agencies, but will coordinate its activities with them. In setting evaluation criteria, SIMAP has incorporated technical norms of the MOH, GAHEF, and GUYWA. As part of the appraisal process, SIMAP will submit the sub-projects for technical review to the State Planning Secretariat and to the corresponding sector ministry or agency. This review process will ensure that there is no duplication with existing services, compliance with sector norms and standards, and no double financing of expenditures. To make the review process as agile as possible, the line ministries will designate a SIMAP liaison person, and coordinating agreements between SIMAP and the sector agency will be made specifying responsibilities on both sides and setting a maximum time for the review process. Any technical observations made by the State Planning Secretariat, the line ministries and sector agencies will be included in the presentation of sub-projects to SIMAP's Board of Directors. Information Mana2ement. Monitoring and Evaluation 8.19 InformatioXi Management. In order to efficiently track SIMAP activities, a computerized management information system has been established. Such an information system is essential to build transparency in the process of selecting sub-projects and to enable efficient tracking of a large number of relatively small sub-projects. This system will allow for internal monitoring of basic elements of SIMAP operations, including fund raising, poverty targeting, the sub-project cycle, and, in part, the impact of SIMAP. 8.20 Annex 8 includes a complete list of indicators for the management information system. Guidelines for the implementation of the system are available in the project file. Key indicators to be reviewed by IDA during project execution pertain to the following areas: - 25 - (a) efficiency of SIMAP operations: number and cost of sub-projects approved per week, number of sub-projects in execution, amount of monthly disbursements, rate of delays in sub-project execution, and administrative costs as a percentage of total SIMAP budget; and (b) efficiency of SIMAP sub-projects: number of physical units completed, such as health posts rehabilitated or food supplements delivered, number of beneficiaries, geographical distribution of sub-projects, cost per unit delivered and cost per beneficiary. 8.21 Monitor-in and Evaluation. SIMAP will complement its internal monitoring system with a series of external monitoring studies. These studies will evaluate SIMAP's performance in specific areas and monitor the impact of its interventions, allowing adjustments to be made where necessary. In August 1991, SIMAP contracted GAHEF to conduct a nationwide Morbidity and Malnutrition Survey. The survey, to be carried out in two rounds (the first round has just been initiated with PPF funding; the second round is planned for the fourth year of the proposed project), will provide data to measure SIMAP's impact on health status. In addition to the Morbidity and Malnutrition Survey, technical assistance funds will allow SIMAP to contract local and international consultants on a short-term basis to assess the quality and impact of the various categories of SIMAP sub-projects, and to evaluate specific aspects of the SIMAP program. Subjects expected to be covered by these external studies include a review of the quality of civil works, a beneficiary assessment of SIMAP sub-projects, an analysis of the mechanisms for cost recovery in water and sanitation sub-projects, and other short-term studies to analyze the adequacy of coverage, project selection criteria, supervision procedures and other aspects relating to the efficiency and effectiveness of SIMAP operations. 8.22 Monitoring of the proposed project will be further enhanced with the implementation of the LSMS. Results from the LSMS will not only provide a tool for evaluating the impact of SIMAP's activities but will also contribute to further the understanding of the extent and depth of poverty and its correlates. This will assist Government in the development of sustainable medium-term policies and programs, in particular in the social sectors. Review by IDA 8.23 SIMAP will have the authority to approve and implement sub-projects costing less than US$50,000 equivalent that fall within agreed eligibility criteria without prior review by IDA. IDA will do ex-ante review of sub- projects that either: (a) have a total cost of more than US$50,000 equivalent; (b) are consistent with SIMAP's objectives but are not covered in the eligibility criteria; or (c) are the first three sub-projects in each sub- project category. IDA will do ex-post review of all sub-projects between US$25,000 and US$50,000 equivalent. IDA will do random ex-post review of sub- projects under US$25,000 equivalent. Final terms of reference for all technical assistance will also be subject to IDA's review prior to selection of consultants. - 26 - 8.24 During negotiations it was agreed that SIMAP will also submit to IDA: (a) monthly reports on the number and nature of sub-projects approved for financing (not later than two weeks after the completion of each month); (b) quarterly reports on its activities, including promotion, targeting and impact evaluation (January 31, April 30, July 31, and October 31 of each year); (c) an annual report on April 30 of each year on the overall execution of the project. SIMAP's annual review will be an essential instrument in the process of planning and implementation of project activities, and will constitute the key monitoring tool for the performance of SIMAP. In addition, the review process will set priority actions to ensure sustainability of SIMAP sub-project activities, in conformity with SIMAP's phase-out plan and with due regard to the project's objectives of setting medium-term policies and programs in the health sector. IDA supervision missions will be scheduled to coincide with the annual reviews. Annex 9 includes specific targets to be reached and the review criteria which will govern the annual review during the project implementation period. In addition, during negotiations it was also agreed that a mid-term project review will take place no later than December 31, 1994, in which the Government, SIMAP, and IDA will exchange views with regard to progress in project implementation. 8.25 In comparison to similar social fund-type projects in other countries, the proposed project will entail less supervision requirements for IDA staff as a result of: (a) having no cofinancing administered by IDA (in contrast to the Bolivia ESF and SIF projects); (b) contracting out procurement activities (para. 9.8); and (c) the lower volume of financing resulting in relatively fewer projects to review. In addition, technical assistance financed under the proposed project is designed to lower supervision requirements for IDA staff by strengthening control over the soundness of SIMAP's operational and administrative procedures and over the quality of sub-project implementation. IX. PROJECT COSTS. -FICING, DISBUlRSEMTS AND PROCUREMENT Prolect Costs 9.1 The proposed project will be carried out over four years; it is defined to include the first two years of SIMAP's sub-project financing commitments (mid-1992 through mid-1994), the first four years of SIMAP's administrative expenses (mid-1992 through mid-1996), and the costs of establishment of an LSMS and the development of a policy framework for the health sector. The total cost of the proposed project is US$11.7 million equivalent. Foreign costs represent about 36 percent of the total. Since specific sub-projects still need to be identified, no contingencies have been calculated: any increase in the expected average sub-project cost (estimated at US$30,000 equivalent) will be reflected as a reduction in the number of sub- projects executed. The credit provides for the financing of SIMAP staff given the fact that SIMAP has a limited life-span, and SIMAP personnel has short-term contracts that will be terminated once SIMAP is phased out. For the same reason, and to permit efficient project execution given the GOG's present financial constraints, administrative costs will be financed over the life of - 27 - the credit. The GOG will finance part of the administrative costs of SIMAP (essentially salaries of support staff). A summary of project costs is shown in Table 9.1 (Annex 10 contains a detailed cost table). Table 9.1: SUMMARY PROJECT COSTS BY COMPONENT *I Local Forelgn Totl Loc Foreign Total % % - GUYS Million- - US$ MUllon- Foreign So* Exchange Coa ,SI .',* yot'&v<.-, t.;:':.' : :",, a WMA .U.9r...... Heth & Nutrton 373.20 151.20 524.40 3.11 1.26 4.37 28.8 37.4 DayCare Centers 108.48 12.72 121.20 0.90 0.11 1.01 10.5 6 Water and Sanitation 226.80 205.20 432.00 1.89 1.71 3.60 47.5 30.8 Tochnroal Aasnce 18.80 7.20 24.00 0.14 0.06 0.20 30.0 1.7 to Paitolpatng MAe Subtotal 725.28 376.32 1101.60 6.04 3.14 9.18 34.2 76.5 Administration 96.00 6.00 102.00 0.80 0.05 0.85 5.9 7.3 Equip., Veh. & Maint 3.60 28.80 32.40 0.03 0.24 0.27 88.9 23 Tonloal Asistance 40.50 49.50 90.00 0.34 OA1 0.75 55.0 6.4 Subtotal 140.10 84.30 224.40 1.17 0.70 1.87 37.6 16.0 2 X ' Y t~~tS:.: os:&;: {: . ' :-:: ' "'. i. ', :,. g :': ;:' S S :''.''g' .'': c," ''R''; .;. . ' . 's...... . &... Sa,rdes 9.60 0.00 9.60 0.08 0.00 0.08 0.0 0.7 EquIpment 0.72 2.88 3.60 0.01 0.02 0.03 80.0 0.3 OperatIonal Exp. 8.40 0.00 8.40 0.07 0.00 0.07 0.0 0.6 Technical Asaistance 2.88 11.52 14.40 0.02 0.10 0.12 60.0 1.0 Subtotl1 21.60 14.40 36.00 0.18 0.12 0.30 40.0 25 Health~~~~~~~~~~~~~~~~~.. ... Sec. .......pL Technical Asdanco 8.40 33.60 42.00 0.07 0.28 0.35 80.0 s0 Subtotal 8.40 33.60 42.00 0.07 0.28 0.35 60.0 3.0 : s.< sodeahr -1404,0it ''w N"0 W i0W 1 Exclusive of taxes and duSs, which are not applicable Includes US$750,000 PPP * 28 - Znanln_laa 9.2 The proposed IDA credit of US$10.3 million represents about 88 percent of total project costs. Counterpart requirements will be met by the Government and sponsoring agencies. The Government will contribute equipment and supplies (e.g., scales, growth charts, vaccines) that will be supplied on a grant basis by PAHO and UNICEF, and salaries of SIMAP support staff. Beneficiary communities will provide contributions of labor or materials. The only anticipated cofinancing arrangement is with the IDB for the financing of SIMAP's administrative costs and technical assistance. The proposed IDA credit will finance staff to manage health, nutrition, and water and sanitation sub- projects, and some additional administrative costs generated by these sub- projects. During negotiations, assurances were obtained that the Government will provide counterpart funds as assigned in the project financing plan presented in Table 9.2 (see also Annex 11). TABLE 9.2: FINANCING PLAN -US$ Mllions IDA 10.30 Govemment 0.53 Beneficlajies 0.57 IDB 0.30 Total 1L1O Cofinanciig Arrangements 9.3 As indicated in the project financing plan (Table 9.2), the proposed project is being cofinanced by IDB on a parallel basis. The cofinancing represents IDB's contribution to support part of administrative costs (including staffing costs) and technical assistance for an estimated amount of US$300,000. IDB's proposed grant of US$2.8 million will also finance sub-projects in the areas of infrastructure and vocational training. Given the different nature and objectives of sub-projects to be financed under the IDB grant, those funds have not been included in the financing plan. On the basis of the limited absorptive capacity of the SIMAP Agency and of the sectors to be financed under the proposed project, no additional cofinancing is being sought at this time. DLLburM8nu 9.4 The proposed IDA Credit will be disbursed over a period of four years, to be completed by June 30, 1996 (Closing Date). Sub-project activities supported by the Credit are expected to be completed by December 31, 1995. The expected disbursement profile i's consistent with similar social fund-type projects in the region. Annex 12, Table 1 contains the estimated disbursement forecast. - 29 - 9.5 Disbursements will be made against the following categories of expenditure: (i) 95 percent against eligible expenditures of health, nutrition, and water and sanitation sub-projects; (ii) 80 percent against eligible expenditures of day-care center sub-projects; (iii) 100 percent of the costs for institutional support; (iv) 100 percent of the costs for implementatior. of the LSMS; and (v) 100 percent of the costs for the development of health sector policy (see Annex 12, Table 2). During negotiations, assurances were obtained that the aggregate amount of expenditures on food items will not exceed US$2.58 million equivalent (or 25% of total credit amount) over the life of the project. 9.6 Documentation of Expenditures. Withdrawal applications for gocds and services with a contract value of US$50,000 equivalent or more will be supported by full documentation. Contracts of less than US$50,000 equivalent, disbursements against expenses not undertaken by contract, and all disbursements under sub- projects will be made on the basis of Statements of Expenditure (SOEs) for which supporting documents will be maintained by SIMAP and will be available for review by IDA staff. A Special Account in US dollars will be opened in the Bank of Guyana, with an initial deposit of US$800,000, corresponding to about four months of expected expenditures. *ccouMts and Auditing 9.7 SIMAP's accounts will be available for inspection by IDA. Annually audited accounts will be submitted to IDA no later than six months following the end of SIMAP's fiscal year. The annual audit reports will include a Statement of Source and Application of Funds, a separate opinion on SOEs, a separate audit report on the project's special account, an opinion of compliance, and a management letter. An opinion on compliance with procurement arrangements specified in credit documents, and on the appropriateness of procurement documentation, will be included in the audit of SOEs. The audit will be performed by a private firm of independent auditors acceptable to IDA and under terms of reference approved by IDA. procurement 9.8 Procurement procedures in the country have been reviewed by IDA and found generally acceptable and not in conflict with IDA procurement policies and guidelines. However, lack of skilled human resources in procurement is a persiste.it problem as a result of high rate of emigration of the most qualified personnel. During negotiations it was agreed that SIMAP will contract a procurement agent acceptable to IDA to carry out procurement activities, including: (a) the preparation of bidding documents, advertising and evaluation of bids for works to be procured under local competitive bidding (LCB), and for goods to be procured under international shopping procedures; and (b) auditing of procurement activities carried out through direct contracting or local shopping procedures. Draft terms of reference for the procurement agent have been prepared. Procurement of goods, works and consultant services will be carried out in accordance with IDA procurement guidelines. A condition of credit effectiveness will be that the procurement agent, acceptable to IDA, has been employed (para. 11.3 (c)). - 30 - Table 9.3: Summary of Proposd Procurement Arrangements (US$ millon .qulvatent) IC ~ atbi ___ Pfoleot Element 1. Works 1.1 Health Facilities 0.35 0.40 0.75 (0.35) (0.38) (0.71) 1.2 Day Care Centers 0.10 0.08 0.18 (0.08) (0.05) (0.13) 1.3 Water Supply 1.60 0.20 1.80 (1.60) (0.10) (1.70) 1.4 Sanitation 0.30 0.20 0.50 (0.20) (0 10) (0.30) 1.5 Wastewater Drainage 0.70 0.40 1.10 (0.70) (0.30) (1 00) 2. Goods 2.1 Medioal Equip., Supplies & Drugs 1.32 1.32 (1.12) (1.12) 2.2 Equipment, Furniture & Suppiles 0.30 0.08 0.38 (0.30) (0.06) (0.38) 2.3 Office Tech. & Veh. 0.12 0.12 (0.12) (0.12) 2.4 Food 1.58 1.00 2.58 (1.45) (0.90) (2.35) 3. Consultancies 3.1 Suppoul to 0.20 0.20 Sponsoring Ag. (0.20) (0.20) 3.2 Technical Aseistance 0.92 0.15 1.07 (0.92) (0.92) 4. Salarde& Oper. Exp. 4.1 SIMAP Ag. 0.65 0.15 0. c0 (0.50) (0.50) 4.2 Survey* 0.15 0.15 (0.14) (0.14) S. Mlsoellaneous 5.1 PPF Refinanoing 0.75 0.75 (0.75) (0.75) g f * :' * . :. ff: - .................... , .-. gfi . g ..................... ,...... ........ ;:... Total Costs 2.30 4.67 4.43 0.30 11.70 (2.30) (4.02) (3.98) (10.30) Note: Pl;ures In parentheses are the respective amounts financed by IDA credIt. Coflnanced In parallel witb the later.Amerecan Development Bank Consultancy vIces hould be procured In ccordence witb World Bank. Guidelines: Use otConaultantu by World Dank Borrowera and by the Wrld sanks xBaecuting Aency(Washlngton, D.C, AuSuat 191).. sl Includes Internatlonal sbopping and local sbopping b/ Includes USS2.26 mIllIon agsrepte of works nd goods procured under direct contractIng procedures cl Caonced by the Inter.AmerIcan Development Bank - 31 - 9.9 For goods and works of sub-projects, the sponsoring agencies will be responsible for procurement. Prior to signing the sub-project contract, SIMAP (or the procurement agent designated by SIMAP) will assure that procurement procedures followed are in compliance with agreed guidelines. For goods to be purchased under the institutional development component through international shopping procedures (vehicles and office technology), SIMAP will be responsible for procurement. 9.10 Standard bidding documents for the procurement of works through LCB procedures will be used to simplify both the reviewing and the bidding processes. During negotiations, assurances were obtained on the use of standard bidding documents acceptable to IDA for the procurement of works through LCB. The procurement arrangements for the project are summarized in Table 9.3. Annex 13 shows a procurement timetable (Project Implementation Schedule) indicating timing of procurement actions, as well as annual contractual payments. Civil Works 9.11 Contracts for works (including construction/rehabilitation of health centers and posts and day-care centers, and extension/rehabilitation of water and sanitation systems) are expected to total about USS4.3 million equivalent and to average about US$30,000 equivalent, with the biggest single project costing no more than US$200,000 equivalent. A very large proportion of civil works will be small in terms of contract value (below US$30,000 equivalent) and spread across various parts of the country. For contracts of more than US$50,000 equivalent, LCB will be carried out using pre-qualification of bidders. For contracts of less than US$50,000 equivalent, up to an aggregate amount of US$1.4 million equivalent, contracts will be awarded on the basis of price quotations obtained from at least two qualified contractors. In remote locations where no more than one qualified contractor is available, the sponsoring agencies could engage in direct contracting up to an aggregate amount for all sub-projects of US$0.7 million equivalent. The contractor will have to agree to SIMAP standard rates. Goods 9.12 Contracts for medical eauiRment. sunRlies and drugs under sub-projects are expected to total about USS1.32 million equivalent. Medical equipment, supplies and drugs will be purchased through international/local shopping procedures (up to an aggregate amount of US$50,000 equivalent for local shopping) with offers from at least three qualified suppliers. 9.13 Contracts for equipment. furniture and supplies to be purchased under sub-projects are expected to total about USS380,000 equivalent. A very large proportion of the contracts will be small (averaging about US$4,000 equivalent) for sub-projects spread across various parts of the country. Local shopping procedures with offers from at least three qualified suppliers will be used. In cases where no more than one quotation from a qualified supplier can be obtained (remote areas), the sponsoring agency could engage in direct purchasing up to an aggregate amount of US$80,000 equivalent. Contract prices will not exceed SIMAP standard prices. - 32 - 9.14 Contragts for office technology eguipment and vehicles to be purchased by SIMAP under the institutional development component are expected to total about US$_12_.0000 equivalent. Given this small amount and the diversity of goods to be purchased under this component, it will not be practical to combine these goods in large packages to be procured under ICB procedures. SIMAP will use international shopping procedures with offers from at least three qualified suppliers. 9.15 Contracts for food to be purchased under sub-projects (the nature of this food is defined in the sub-project eligibility criteria) are expected to total about &jSS2.58 million equivalent. Food will be purchased at the local level by the sponsoring agency on a weekly basis and quantities of each purchase will be small. In order to promote competition and guarantee the lowest prices, SIMAP will encourage the packaging of contracts with different sponsoring agencies in the same area and contracts will be made for a minimum period of three months. SIMAP will determine, in the appraisal process, the presence of qualified suppliers in the sub-project area. Local shopping procedures, with offers from at least two suppliers, will be used to procure food in areas where more than one supplier is available. Direct purchasing (up to an aggregate amount of US$1.2 million equivalent) will be carried out in areas where it is determined to SIMAP satisfaction that only one supplier is available and provided that prices are within SIMAP's reference price data base. Consultants 9.16 Consultants required for the project will be hired in accordance with IDA's guidelines for the Use of Consultants. IDA's Review 9.17 Prior review by IDA in accordance with IDA guidelines will be carried out for: (a) civil-works contracts valued at US$100,000 equivalent or above to be procured under LCB procedures; and (b) the first three civil-works contracts to be procured under LCB. It is estimated that, during the life of the project, about 20 contracts and award recommendations (representing about 20 Percent of total nroject costs) will require prior review by IDA. In addition, the procurement agent will review ex-post all contracts and bid evaluations for works and goods purchased under local shopping procedures and will carry out a selective review of a representative sample of contracts under direct purchasing arrangements (including at least 15 percent of all contracts). The findings of the procurement agent will be submitted to IDA in semi-annual reports. During the annual reviews, IDA staff will discuss the results of the reviews by the procurement agent and carry out a selective review of contracts for works under US$100,000 equivalent procured under LCB and of contracts for works and goods purchased under shopping and direct contracting procedures. During negotiations, assurances were obtained that: (a) SIMAP will submit to IDA for prior review: (i) bidding documents and award recommendations for contracts of civil works valued at US$100,000 equivalent or above to be procured under LCB procedures; and (ii) bidding documents and award recommendations for the first three civil works contracts. - 33 - X. BENEFITS AND RISKS 10.1 Benefits. The proposed project would help cushion the negative effects of adjustment, while at the same time improving the country's capacity to design, implement, and monitor health, nutrition, sanitation and other community- initiated programs. It would have direct effects on the nutritional status of about 150,000 women of child-bearing age, and of 80,000 children under five, and would provide associated services such as primary health care and basic sanitation. Results from the LSMS would supply not only a tool for evaluating the impact of SIMAP's activities but would also contribute to further the understanding of the extent and depth of poverty and its correlates. This, coupled with the implementation of the phase-out plan for SIMAP and the preparation of an investment plan in the health and nutrition sectors, would help the GOG in the development of sustainable medium-term policies and programs in the social sectors. 10.2 Risks. The project faces several risks: (a) that SIMAP may succumb to political pressure and approve sub-projects that are inconsistent with agreed selection criteria; (b) that SIMAP's,credibility may be eroded as a result of a prolonged hiatus between its launching and the start of operations; and (c) that demand for health and nutrition projects may be limited by the lack of project implementation capacity of NGOs and grass roots organizations. The project would address these risks by: (a) the careful selection of technical staff, the development of well-defined operating procedures and project eligibility criteria, attention to institutional development supported by frequent supervision, annual reviews and technical assistance; (b) the definition of a core pipeline of sub-projects to be financed during the first year of implementation; and (c) the emphasis on promotion activities during the project preparation phase including the broadening of SIMAP's current promotion strategies beyond NGOs and grass roots organizations to include national and local government agencies. XI. AGREENENTS REACHED AND RECOMHENDATION Areesents Reached 11.1 Prior to Negotiations, (a) the Government submitted to IDA the revised salary scale which was approved by the Ministry of Finance in September 1991, that will guarantee quality staffing at SIMAP (para. 7.5); (b) the Government submitted to IDA a dated plan of action to phase- out SIMAP and gradually integrate its activities into existing government agencies (para. 8.2); and (c) SIMAP submitted to IDA a list and profiles of sub-projects suitable for financing during the first year of implementation (para. 8.6). 34 - 11.2 It was agreed during Negotiations that: (a) SIMAP will be maintained fully staffed with qualified personnel during the life of the project. The Minister of Finance agreed that SIMAP salaries will be reviewed from time to time to ensure that salaries remain competitive (para. 7.5); (b) the proposed phase-out plan will be implemented in accordance with the agreed objectives and time frame (para. 8.2); (c) SINAP will maintain at all times a reference price data base satisfactory to IDA (para. 8.11); (d) the Government will issue, not later than December 31, 1993, a nutrition policy statement defining policies and programs designed to meet the nutritional needs of pregnant and lactating women and children under five years over a medium-term, and to start the execution of a specific plan of action to put into effect such policies and programs according to a timetable satisfactory to IDA (para. 8.13); (e) procedures for IDA's sub-project review will be followed by SIMAP; and that SIMAP will submit to IDA: (a) monthly reports on the number and nature of sub-projects approved for financing (not later than two weeks after the completion of each month); (b) quarterly reports on its activities, including promotion, targeting and impact evaluation (January 31, April 30, July 31, and October 31 of each year); and (c) an annual report on April 30 of each year on the overall execution of the project (para 8.24); (f) a mid-term review of the project will take place not later than April 30 of each year (para. 8.24); (g) the Government will provide counterpart funds as assigned in the project financing plan (para. 9.2); (h) the aggregate amount of expenditures on food items will not exceed US$2.58 million equivalent over the life of the project (para. 9.5); (i) SINAP will contract a procurement agent acceptable to IDA to carry out procurement activities under the proposed project, including procurement audits of contracts to be procured under local shopping and direct contracting procedures (para. 9.8); (j) SIMAP will use standard bidding documents acceptable to IDA for the procurement of works through LCB (para. 9.10); and (k) SIMAP will submit to IDA for prior review: (i) bidding documents and award recommendations for contracts of civil works valued at - 35 - US$100,000 equivalent or above to be procured under LCB procedures; and (ii) bidding documents and award recommendations for the first three civil works contracts (para. 9.17). 11.3 Conditions of Credit Effectiveness will be that: (a) the revised salary scale, satisfactory to IDA, is implemented (para. 7.5); (b) the contractual arrangement between the Borrower and SIMAP specifying the mechanisms through which proceeds of the proposed credit will be passed on to SIMAP has been duly signed and ratified (para. 8.1); and (c) the procurement agent, acceptable to IDA, has been employed (para. 9.8). 11.4 Subject to the above conditions and assurances, the proposed project will constitute a suitable basis for an IDA credit of SDR 7.5 million (US$10.3 million equivalent) to Guyana. 37- GUYANA GUYANA Page 1 of 6 SIMAP/HEALTH. NUTRITION. AND WATER AND SANITATION-PROJECT OFFICIAL ORDER 79/90 535 (EXTRAORDINMY) OF GUYANA *ublsbtb bp tbe Antboritp of tbe dSotrnmtnt. GEORGETOWN, SATURDAY, 18TH AUGUST, 1990 TABLE OF CONTEINS FAGS FR5Fr SUPPLMW LEGAL SUPPLZM4VI A ACTS- MIL S. 3UeURD LEGLATION 4rder No. 53 og 1990-Thb Social Impact Ameliortdon Prmme Board Order 1990 .. .. % .. .. C. Du-" -. _L GEORCGrLON Dcmeura -Printed and Published en:ry Sawrday and a -such I&tM y Days at way be direted by the Gov er=xe, by Gavsa National Pulates Limited Ja&Wal Etistte, RuiMvldL Gcorseto. SATURDAY, 18TI AUGUST, .1990 A.NNEX 1 Page 2 of 6 -38 - THE OFFICIAL GAZETTE 18TH -AUGUST,, 1990 LEGAL SUPPLEMENT 13B r-UYANA No. 53 of 1990 ORDER Made Under THE PUBLIC CORPORATIONS ACT 1988 (No. 21 of 1988) IN EXERCISm OF6 THE POWERS CONFERRED UPON THE MINISTER BY SPOTIONS 3, 4 MAID 5 OF THE- PUBLIC CORPORATIONS ACT, I HEREBY MAKE THE FOLLOWING ORDER:- 1. This Order may be cited as the Social Impact Amell-. citation. M14n irogmme Board Order' 1990. 1.(1) In this Order - (a) "Board' means *>,PoeIg Impact Amelora- tion Pogiamnme Beard e4tablished by. clause (b) "concerned Minlster" means the Mninstei assigned responsibility for the Board or, where there Is no such Minister, the Pre' dent. (2) The Board and Its employees together shall be known as the Social Impact Amelioration Programme Agency (hereinafter referred to as the "Agency"). StabUsh.' 3. (1) There is hereby estabLshed a publlc corporation emotuutuo to be known as the Social Impact Amelioration Programme of 5o~t,^ Board (2) The Board shall be a corporation aggregate con sisting of a chairman, and such other members, who shall be appointed by the concerned Minister unde section 4 of the Act as modified by clause 6. Jlw'utans 4. (1) The Board shall, subject to the availability of °'' &funds to the Board, approve projects and programnmes and provide, either wholly or partially, finances to municipal councils, reglonal administrations or other local democratie organs, commrunity groups and non-governmental organisa- tions with charitable and development goals, for the execution of such projects or programmes which wM serve to alleviate the negative effects, of structural economlc adjustment * measures taken by the Government, on the most severely affected groups in the country. (2) In approving .a project or programme under para graph (1), the Board shall have regard to all relevant matters, Including the following - (a) the size of the proposed project or r-- gramme; 39 ANNEX 1 - 39- Page 3 of 6 (b) wbether the proposed project or programmp can be undertaken expeditiously; (c) the time required for the completion of the proposed project; (d) whether the proposed prolect or programme has the capacity to demonstrate technical, Instftuflonal and economic viability according to established project approval criteria; (e). whether the proposed Proiect dr programme is in the sectoral priority areas of public services and productive Infrastructure, social services and productive income generation; (f) the operating costs in relation to the proposed project or programme; and IS) where the applicant is an organi-ation or other group of persons, whether the organisa- tion or group has been incorporated or regis- tered under any written law. (3) The Board shall have exclusive power - (a) to approve- (i) the procedures and criteria for project and programme selection, and the pro- jects and programmes submitted for Its consideration in acocrdance therewith; (ii) its policies regarding the nianagement of projects, programmes and activities, its financial regulations and tendering procedures; (iil) the terms and conditions of appointment of the Executive Director; (iv; the budget; and (v) the rules prescribing the procedures of, including the quorum for, the meetings of the Board, and the manner In which it will transact its business; (b) to accept fgrants. gifts fr loan funds frora any person in or outside Guyana; and (e) to submit to the concerned Minister reports on the activities of the Agency on ra timely and regular basis. (4) There sh2U be an Executive Director appointed by the Board for a perind of three years or such shorter period ag may be determined by the Board. (5) The Executive Director shall be the chief executive officer of the Board and shall, subject to the general direction and control of the Board, be responsible for implementing the decisions of the Board and the management of the affairs and activities of the Agency. ANNEX 1 40- Page 74 -of 6 I"" Sc- (6) Without prejudice to the provlsions of par3graph (5), the Executive Director shall be responsible for the activi- ties and fupetions referred to in the First Schedule. C7) All proposals made by the Executive Director to the Board shall be considered app oved, unless rejected by a majority of the Board and all other proposals shall be con- sidered rejected, unless approved by a majority of the Board. coGSUlUWce 5. All persons employed, immediately before the tent ao commencement of this Order, in the Social Impace Ameliora- __g ,, tlon Programme Unit of the Ministry of Culture and Social otlhyi -. Development shall be continued in employment by the Board in suitable positions, having regard to the positions they held Immediately before such commencement in the said Unit. Zxdc ul4M Q. The proisions of the Act shall apply to the Board "tUOn *I with the following exclusions sd modifications - the ACt. (a) for section 4'3), (4, (5) and (6) the following shall be deemed to be substituted- "(3) The Board shall consist of- (a) one member to represent the Ministry of Finance; (b) two members appointed on a rota- tional basis to represent the Minis- tries of Health, Education, Agriculture and Works; (c) three members, one each to be chosen from panels of three persons to be submitted by the respective interest group to repre- sent the private sector business and industrial undertaldngs, non- governmental organisations and the faculties of engineering, economics or social studies of the University of Guyana. * (4) The Executive Director shall be an ex officio member of the Boar4. (5) Ihe members of the Board referred to in subsection (3) shall'be appoiited by the Minlster and shall hold office for a perlod of one year but shall be eligible for re-appointmeni. (6) The members of the Board shall elect a chairman from among themselves." (b) references to "general manager" shall be construed ik rbferences to the "Executive Directoe'; ANNEX 1 -41- Page 5 of 6 (c) sections. 15 and 34 and Part ViI shall be deemed'to be deleted; (d) section 17 shall' to the extent to which It is inconsistent with the provisions of this Order, be read and construed with such modifications as may be necessary to bring it into confor- mity with this Order; te3 section 25 shall be deemed to be deleted and the fbllowing section substituted therefor- DIn"r,ec,tor 25. (1) The Board shall emplo and other an Executive Director on such itiff, terms and conditions (including salary and allowances) as it deenms fit. (2) There shall be such other offlcers and employees as are necessary to carry out the func- tions of the Board and the Agency." (fl in section 81(1), after paragraph (a) the follow- ing paagraph shall be deemed to be inserted as paragraph (aa) - "(aa) sums received as grants, gifts or othervJise from' any per- soil, other thani the Government of Guyana, in or outside Guyana;" 7. The movable property of the State referred to in vesu of the Second Schedule shall vest in the Agency with effect from s.A the commencement of this Order. 5ce4. FIRST SCHEDULE cl. 4(a) Rbsponsibillties of Executive Director 1. The Executive Directoi shall be responsible- (a) for direcding - (i) the overall planning, implementation and internal evaluation of the projects, pro- grammes anduactivities of the Board and the Agency; (iJ) the financial atdvities of the Board and the Agency, including;Jund-raising and the co- ordination of the flow and use of funds by the Board and the Agency. (b) for proposing for the consideration and approval of the Board, policies, regulations and pro- cedures; the projects, .programmes, and activitnes to be financed, and the budget. (c) for hiring the officers and employees necessary for carrying out the functions of the Board and the Agency, to determine their remuneration and the terms and conditions of their employ- mnent In accordance with budget, and to dismiss them. ANNEX 1 -42- Page 6 of 6 (d) for keeping the Board informed on a timely and regular basis of all the activities of the Agency. 2. The Executive Director, or such other officers of the Agency.as may be designated by him, shall be re- sponsible for the following - (i) to establsh contact with Government Ministries. external agencies, local authorities and com- munity groups, as the Executive Director may deem necessary to carry out the Agency's goals; (di) to use all appropriate means to promote public awareness of the Agfncy's work and, the assist- ance it can provlde; and (Xii) to make presentations of the Agency's activities to potental donor organisations, and provide them with activity reports and statements of uses of funds provided by them. SECOND SCHEDULE cl. 7 1. ONE IBM PS/2' MODEL COMPUTER. SERIAL NO. 72- 601. 2. ONE SUZUKI VITARA FOUR WHEEL DRIVE JEEP (1990 MODEL) VEHICLE NO. PDD 1151. 8. ONE SUZUKI SAMURAI FOUR WHEEL DRIVE JEEP (1990 MODEL) VEHICLE NO. PDD 1397. 4.. TWO EEC SUPER DE LUXE TABLE MODEL FANS. 5. ONE WOODEN EXECUTIVE DESIR 6. THREE WOODEN OFFICE CHAIRS. 7. THREE WOODEN OFFICE DESKS. 8. ONE 18" OLIVETTI TYPEWRITER SERIAL NO. 3218878. 9. ONE WESTINGHOUSE AIR CONDITIONER. 10. ONE ICEBERG REFRlIGERATOR MODEL NO. G525 SERIAL NO. 109827. 11. ONE 14" DAYTON PEDESTAL FAN. Made tbis 9th day of August, 1990. H. D. Hoyte, President 43 - SIUMAPHEALTH, NUTRITION. AND WATER AND SANITATION PROJEa ORGANIZATIONAL STRUCTURE OF SIHAP AGENCY XCUTIVE DIRCTOR 1'~~~~~~~~~~~MO IIJ EXECUTIVE SECRETARY OPERATIONS MANAGER EXTERNAL SUPPORT * Legal Services * Ex-Post Evaluation Services Technical Assistance Consultants FINANCE DEPARTMENT PROJECTS DEPARTMENT MIS * Administration * Infrastructure Division DEPARTMENT * Accounting * Productive Activities Division * Social Services Division . -44- ANNEX 3 Page 1 of 7 G=a SIMAP HEALTt. NUTRITION. AND WATER AND SANITATION PROJECT SOCIAL SECTORS Table 1: ESTIMATED END OF YEAR POPULATION BY SEX - GUYANA, 1977 - 1989 . _ I _ _ I1 _ _- I _ _ _ Year Both Sexes Male Female 1977 744,000 370,000 374,000 1978 750,000 373,000 377,000 1979 756,000 376,000 380,000 1980 759,000 376,000 383,000 1981 758,000 375,500 382,500 1982 757,600 375,300 382,400 1983 757,300 375,200 382,100 1984 756,900 375,000 381,900 1985 756,500 374,800 381,700 1986 756,100 374,300 381,800 1987 755,700 374,100 381,600 1988 755,6eo 374,100 381,500 1989 755,200 373,900 381,300 Note: Figures adjusted to reflect unreported migration. Figures revised from 1981-1984. Source: Statistical Bureau. Table 2: CHILDREN 0-14 YEARS AS PERCENTAGE OF THE TOTAL POPULATION Age 1970 J 1980 1986 0 - 4 15.8 12.8 11.1 5 - 9 16.9 14.0 f 12.5 10 - 14 14.4 1 13.8 13.2 TOTAL 47.1 40.6 36.8 Source: Census of Guyana 1970, 1980; GUYREDEM 1987. Page 2 of 7 - 45 - Table 3: AREA AND POPULATION BY REGIONS GUYANA, 1986 Reg. Area Population 2 Density Z Rural Sq. 1 _T Sq. _ Miles M Miles | _ _ - = _ -g 1 7,853 18,516 2.4 2.4 100.0 2 2,392 41,966 5.6 17.5 100.0 3 1,450 102,760 13.6 70.9 100.0 4 862 310,758 41.1 360.5 51.6 5 1,610 55,556 7.3 34.5 100.0 6 13,993 148,967 19.7 10.6 76.8 7 18,229 17,941 2.4 0.9 100.0 8 7,742 5,672 0.7 0.7 100.0 9 22,313 15,338 2.0 0.7 100.0 10 6,595 38,598 5.1 5.8 24.8 TOTAL 83 756,072 100.0 T 9.1 Sources Statistical Bureau GUYREDEH Conference, 7-8 July 1987, Georgetown, Guyana. Table 4: SELECTED SOCIAL INDICATORS IN THE REGION Country (1) (2) (3) Infant Z Infants Prim. School Mortal. Rate with Low Enrollment (per thious.) Birth Weigh Ratio 1980 1982-1987 1980 Guyana 47.8 11 100 Suriname n/a 13 115 Dom. Rep. 78.6 16 114 Haiti 132.4 17 69 Belize 46.8 c/U n/a Barbadoa 13.6 10 109 LAC Average nla 12 n/a Souree (1) & (2) World Tables, 1988-8$ Ed., The World Bank (2) Human Resources in L&Cs Basic Indicators, LATHR. - 46 - Page 3 of 7 Table 5s LEADING CAUSES OF DEATH IN CHILDREN, 1984 CAUSES O DEATH c ildren .cl Children 1-4 Rank 2 Total Rank S total malnutrition 1 27.9 2 20.9 Digestive System 2 22.4 1 35.3 Respiratory Syst. 4 10.6 3 11.4 Perinetal Cond. 3 16.9 - 111-Defined 5 5.3 9 3.5 Hematologic - - 4 4.9 Nervous System - - _5 3.9 Source: PAHO/Ministry of Health Table 6s IMMUNIZATION STATUS OF INFANTS 11984-88) PERCENTAGE IHMUNIZED Vaccines 1984 1985 1986 j 1987 1988 BCG 75.5 68.6 64.0 DPT 69.8 75.0 63.7 67.0 64.3 OPV 66.8 77.2 67.0 76.7 69.4 measles 56.0 39 5 42.2 52.2 55.2 Source: PAHO/Ministry of Health, 1989 Table :t NUTRITIONAL STATUS O CHILDREN UNDER 5 Degree of Malnutrition 1987 Veight for Ae Total X 12 of R f . Stanterd) _ Severe <60 956 2.7 Mild/Moderate 60-C0O 7,422 20.6 Normal 80-120 25,792 71.4 Obesity p120 1,924 5.3 TOTAL I 36,094 ; 100.0 Sources CMP1, 1987 - 47 - a Page 4 of 7 Table St HB TESTS OF PREGNANT WOMEN AT HEALTH CENTERS GUYANA, 1985 - 1987 Year No. of BB less Women 11 g./dl J 2 1985 4,482 2,538 56.6 1986 5,417 3,077 56.8 1987 _ 9,060 6,391 70.5 Source: Ministry of Health. Maternal and Child Department. Table 9: PREVALENCE OF ANAEMIA AMONG SCHOOL CHILDREN GUYANA, 1981 - 1986 Year No. with No. vith 2 Likely 8B BB Anaemis cll g./dl 11 g./dl and over 1981 8,245 2,641 76 1982 8,803 2,953 75 1983 5,810 2,614 69 1984 6,)99 2,791 70 1985 4,404 2,401 64 1986 4,024 2,608 61 Source: Ministry of Health. Annual Reports 1981-1986. ANNEX 3 -48- Page 5 of 7 Table 10: EEALTH FACILITIES IN GUYANA Region Regional District Health Health Other ______________ Hospitals Hospitals Centers Posts Hoop.__ _ Region I 0 3 6 13 Region 2 1 - 1 9 2 Region 3 1 3 15 0 Region 4 0 0 18 0 Region 5 0 2 14 0 Region 6 1 3 21 0 Psychiatric Region 7 0 1 3 12 Region 8 0 0 2 14 Region 9 0 2 3 20 RegionlO 1 1 6 4 Georgetown 0 0 7 0 Georgetown Palm. Aged Children'o TOTAL ~~4 16 j 104 (65 1 ______ Note: a) Both hospitals in Region 10 are managed by GUYHINE. b) Also In Georgetown there Is a Cheat Clinic and Imunization Center. c) There are 7 private hospitela ln Guyana; 6 in Georgetown and I In Region 6. d) The figures for the regions with health posts are approximate. ~49. _Page 6 of 7 Table 1: MEDICAL MANPOWER Medical T ToLAl Per 10,000 Manpower Population Physicians 164 2.00 Dentists 16 0.20 Nurses 789 9.80 Midwives 409 5.10 Nurse Assistants 875 10.90 Dental Nurse/Aides 37 0.50 Medex 126 1.60 Medical Technologists 49 0.60 Radiographers and 17 0.20 Technicians Pharmacists 38 0.50 Dispensary Assistants 46 0.60 Public Health 58 0.70 Inspectors Hospital Administrators 3 0.04 Statistical Clerks 15 0.20 Other Staff 165 2.10 Table 12: HATH CARE PERSONNEL PER 100,000 POPULATION Guyana Suriname French Trinidad Jamaica Venezuela Guyana & Tobago l Physicians 2.0 8.7 15.9 10.6 4.9 14.3 Dentlsts 0.2 0.6 3.4 0.9 0.5 2.6 l Nurses 9.8 27.0 98.6 29.2 15.8 5.3 Nurse Ass. 10.9 12.8 9.0 10.3 4.8 3.7 -~~~~~~~~~~~~~~~~~~~~- Sources Health Conditions in the Amoricas, PABO, 1986. Ministry of Bealth, Guyana, 1987. -50-ANE Page 7 of 7 Table 13: ESTIX&TED NUMBER OF CHILDREN COVE=RD BY HEALTH SERVICES, 1983. Age Group t ChIldrea 2 of Target (months) Population 0-11 20,000 99 12-23 11,288 58 24-59 15,448 27 0-59 46,736 48 SourS: Ministry of Health. Annual Report, 1983. - 51 Page 1 of 5 SIMAP/HEALTH. NUTRITION. AND WATER AND SANITATION PROJECT NUTRITION PROGRAMS Maternal and Child Programs 1. Nutrition programs are incorporated into maternal and child programs carried out by the Maternal and Child Department of the Ministry of Health. Ante-natal care is provided to pregnant women including haemoglobin control and iron and vitamin supplementation. Health check-ups for infants and children under 5 years old are scheduled once per month in the first year of life, once every other month in the second year, and twice per year in the third, fourth and fifth years of life. These visits include growth monitoring, nutrition education of mothers, and other primary health care activities, such as immunizations and control of diarrhoeal and acute respiratory diseases. Maternal and child health clinics have fixed schedules for the provision of specific services (i.e. ante-natal control visits occur once a week on a specific day, children health check-ups on another day, and malnourished children are seen once a month on a pre-defined date). 2. Currently, the MOH, in collaboration with UNICEF, PAHO and the Caribbean Food and Nutrition Institute, is in the process of implementing a project to increase coverage of growth monitoring programs for children under five. This project includes the introduction of the Caribbean Growth Chart into the primary health care system, training of health care workers, including community health care workers in growth monitoring techniques, increased emphasis on nutrition education (in particular in breastfeeding and weaning practices), and information dissemination campaigns. UNICEF will provide cardboard and other materials for the production of growth charts, support the training of health care workers, and finance the printing of a revised Maternal and Child Health Manual. The project aims at increasing the coverage of the growth monitoring program to about 95,000 children (from its current level of about 60,000). The project does not include food supplementation schemes. Community Resource Person (CRP) Project 3. The MOH, in collaboration with CFNI and PAHO, is also carrying out a pilot project in 18 communities with high levels of malnutrition11. The objective of the project is to increase the coverage of maternal and child health programs through the active involvement of community members in maternal and child activities. These community members, who have to live in the community and m.st have completed primary education to qualify for the 1/ Comutities were selected in Regions 3, 4, 5 and 10. - 52 - ANNEX 4 Page 2 of 5 program, are being trained to raise the community's awareness on issues of child growth, health and nutrition, and to motivate parents to take children regularly to clinics. Increased education at the community level, and the early identification of malnourished and/or sick children is expected to increase attendance to maternal and child clinics. An evaluation of the program carried out in January 1991 showed encouraging initial results, including a high motivation of community workers, higher degrees of awareness of sound nutrition and health practices among targeted communities and increasing levels of attendance of children to clinics. Day-Care Centers Program 4. The Georgetown Municipal Day-Care Service is the only formal organization providing day-care services in Guyana. While, in general, children in rural areas are taken care of by extended family units, the problem of children left unattended has become pervasive in urban areas. The Georgetown Municipal day-care service has five centers with a total of 430 children with ages ranging from 9 months to 5 years and 9 months. There are two more day-care centers in Linden, one in Corriverton (Courantyne River Town), and other private day-care centers in Georgetown: two associated with the Mothers' Union, one with the YMCA, one run by a private agency (WYLPA), and one owned by a private person. In total, day-care centers cover only about 1,000 children nationwide. 5. The Georgetown Municipal Day-Care Service provides two snacks and a lunch to children. Diets are balanced among the four groups of food, including milk, fish, vegetables, and fruits (fish is preferred over beef because of its lower price but is not usually available in some months of the year). Food is obtained from the local market. Snacks consist of a half glass of milk (around 2 ounces) and 2 or 3 biscuits per child and lunch includes a main dish and a dessert. Two of the main problems of those centers are security (food is stolen if storage areas are not secured) and the contamination of the water supply (all water needs to be boiled prior to its utilization). Kitchen utensils for the program have been provided by UNICEF. During one of the field visits of one of the preparation missions to one of the day-care centers (South Road Center), IDA noted that the kitchen was clean and well equipped, and was staffed with 2 well-trained cooks. 6. Staff for the day-care centers is trained in an extramural program run by the University of Guyana. The training program consists of two different levels: a basic training pxogram, and an advanced training program. Each of these programs currently enrolls 20 students. Currently, the Municipality employs 90 persons distributed in the centers as follows: one staff per five babies (9 months to 1 year-3 months), one staff per seven children (1 year-3 months to 2 years), one staff per eight children (2 to 3 years), one staff per 10 children (3 to 4 years), and one staff per 15 children (over 4 years). Children health check-ups (including immunizations) are carried out by municipal health centers prior to admission. Sick children are not accepted, and malnourished children receive special attention, 53 - Page 3 of 5 including special diets (their parents are also enrolled in a nutrition education program). Funding for the Day-Care Center Program comes from the Georgetown Municipality. Parents pay only G$100 a month per child (less than US$1 in April 1991). Demand for the program far exceeds capacity and the number of applicants in waiting-lists is rapidly increasing. 7. In addition to the day-care system a "play-group" system has been established. This system caters to children between 2 years-9 months and 3 years-9 months, and offers day-care and early stimulation programs during the morning (9-12 a.m.). "Play-group" programs do not involve the provision of food. There are 11 of these centers nationwide with a coverage of around 800 children. Red Cross Recovery Center 8. A Red Cross convalescent home for abandoned children exists in Georgetown. Most of the children arriving at the home are malnourished, and a program has been set up to offer special child care, including the provision of diets for nutritional recovery. The home can accommodate about 30 children from 9 months to 5 years. Following recovery children are given for adoption or sent to an orphanage. Funding for the convalescent home is from the Red Cross in Geneva and from donations, especially from Guyanese residing abroad. School and Nursers School Feedinz Program 9. The World Food Program (WFP) has provided support to two food supplementation projects: (a) a feeding program for children in nursery school; and (b) a supplementary feeding program for school children (including the extension of the nursery school program and a primary school feeding program). 10. The Nursery School Feeding Program. This project, initiated in 1983, targets children from three years and nine months to five years and nine months enrolled in Nursery Schools and is aimed at supplying the Government with food commodities (i.e., wheat flour, dried skim milk, wheat-soya blend and edible fat) and providing assistance in the distribution of commodities. The program, which planned to cover 20,000 children by 1988 (see Table 1), ran into implementation problems as a result of the weak institutional capacity of the Ministry of Education (i.e., lack of motivated personnel and inadequate transportation and storage facilities, and deterioration of the physical condition of schools) and the lack of safe water supply and utensils to reconstitute the powder milk into liquid milk. As a result of the program's problems, the program was extended for another five years (in conjunction with the new primary school feeding program) and biscuit production and distribution was contracted with the private sector (TRISCO, a subsidiary of Banks D.I.H. Limited). ANEX 4 54 - Page 4 of 5 Table Is NURSERY SCHOOL CHILDREN TARGETED FOR SCHOOL FEEDING PROGRAM Targ,eted Targeted Actual Actual No. No. No. No. Year of of of school children school children days |das fed 1984 15,000 195 17,999 121 1985 20,000 195 13,746 120 1986 25,000 195 11,631 84 1987 30,000 195 14,925 96 1988 20,000 195 5,807 88 1989 - - 14,379 142 Source: WPP Project Guyan 41421Q "Supplementary Feedln8 of PrSmary School Children. 11. The School Feeding Program. This program, initiated in May 1990, came as a response to the Government's Social Impact Amelioration Program (SIMAP) and is aimed at expanding the Nursery School Program to 80,000 primary school children. Additional financing for these programs has been pledged by the EEC (through proceeds of the sale of wheat), th_ Canadian Government (through proceeds of fertilizer sales), the Italian Government (through proceeds from the sale of rice) and the French Government. The program has the long-term objective of supporting development of the education system in Guyana. In the short-term it aims at encouraging atzendance and reducing drop-out rates. This objective is particularly important if one considers that attendance of primary school students has been decreasing in the last years to less than 60X. 12. The program provides nursery and primary school children with a supplementary snack consisting of four biscuits and a glass of milk (the program covers 195 school days per year). Milk and biscuits are distributed from the central level to three regional distribution centers. Distribution is carried out with 3 vehicles and managed by four full-time workers funded by the Ministry of Education. School headmasters are responsible for the program at the school level. Biscuits and milk are delivered every three weeks and milk is reconstituted every day by parents or school teachers. The main problems are associated with the lack of utenslIs to reconstitute the milk as well as with the safety of the water supply. Program costs are around US$1.7 million (of which WFP finances US$1.2 million). The Cerex Proggra 13. In October 1978, the USAID-financed Guyana Weaning Food Project began to develop an appropriate weaning food establishing a manufacturing plant to distribute food made in part from Title II commodities to the target group (children under 5 years of age) predominantly through retail stores, and secondarily through maternal child clinics. In 1981. an evaluation was conducted and concluded that the project has been successful In achieving its major objectives: an acceptable weaning food product (that was named CEREX) had been developed and a factory built and put into successful operation by the implementing agency, Guyana Pharmaceutical Corporation (GPC). The product - 55 - ANNL 4 Page 5 of 5 was produced in part from locally grown crops (rice and sugar) and in part from imported Title II commodities (corn meal, soy bean flour, soy bean oil, and milk powder) (see Table 2). Table 2: PERCENTAGE OF CEREX INGREDIENTS AND SOURCE. Ingredients j 2 Source Rice, polished 15.6 Local production Sugar 8.1 Local production Corn meal 37.4 PL 480, Title II Soy bean flour 18.9 PL 480, Title I1 Milk powder 9.5 PL 480, Title II Soy bean oil 7.3 PL 480, Title II Mineral premix 3.1 USAID Grant, U.S. Vitamin premix 0.1 USAID Grant, U.S. Source: USAID, 1985. 14. At the initial stage of the project, CEREX wa, sold throughout Guyana in half pound packets at a subsidized price (G$ 0.50 per packet in 1981) which covered essentially all manufacturing and distribution costs. By mid-1981, Cerex sales had grown to an annualized rate of 460 tons per year. A July 1981 national consumer survey indicated that roughly 66Z of children under 5 in Guyana consumed Cerex, that half of all Cerex consumers were under 5, and 201 were under 2, and that among children under 2 who consumed Cerex, 70? had 3 servings a day. However, a 581 of weaning children consumed Cerex from a bottle rather than by spoon feeding, as it was indicated, and a substantial amount of Cerex appeared to be consumed by older children and adults, thereby diverting subsidies to non targeted persons. In addition Guyanese programs to promote local production of corn and soy bean had not been successful, thus threatening the goal of achieving full use of local crops to produce Cerex. 15. In a second phase of the project, the HOH initiated the delivery of Cerex to children attending health clinics. The distribution scheme and the product were well accepted by the beneficiaries and health personnel, and attendance to health centers increased substantially. The program, however, suffered from erratic distribution mechanisms and manufacturing problems (related to equipment breakdowns, lack of a reliable and stable power sourcA, and absence of an adequate water source). The project was phased out in 1987, and the CEREX plant (with a potential production of 1,500 Tons of Cerex per year) was shut-down. To this date, however, health workers and beneficiaries consider CEREX to be an excellent weaning food that was well accepted by mothers and children. Food Fortification Programs 16. Wheat flour is the only basic food staple that is currently being fortified in Guyana. Wheat flour is imported and enriched with B vitamins, calcium and iron. - 56 - ANNEX 6 GUYANA SIMAP/HEALTH, NUTRITION. AND WATER AND SANITATION PROJECT INSTITUTIONAL DEVELOPMENT COMPONENT TECHNICAL ASSISTANCE Technical Assistance Administ.rtion International 1 month 12,000 MI. U . .,. . . . ... . ... . . . . . . . - .. . . -- . ;..::.s:.; International 3 months 36,000 National 24 months 18,000 International 1 month 12,000 Unit dost Data Base.:., International 1 month 12,000 phratTiohal Manual International 3 months 36,000 Food Supplementatlon International 3 months 36,000 National 26 months 54,000 SUb-Protet impiementatlon'. International 12 months 60,000 Phase-out Plan.-.::: International 2 months 24,000 _MonJtoring and Evaluation. International 5 months 60,000 Total Man-months Technical Assistance Intemational: 31 man-month National: 50 man-month Sub-Totai C,osts Technical Assistance 300,000 Procurement and External Audits Procurement Intemational Procurement 190,000 Agency *Extemral Audit External Auditing Firm 50,000 Sub-Total Costs Procurement and Audit 240,000 tl Costs 40,000 -57 -EX 6 Page 1 of 6 GUYANA SIMAP/HEALTH. NUTRITION. AND WATER AND SANITATION PROJECT CRITERIA FOR SUB-PROJECT ELIGIBILITY 1. Categories of eligible health, nutrition, and water and sanitation sub-projects are defined in accordance with the following general criteria: (a) consistency with Government's priorities in the health sector; (b) capacity to reach the poorest and most underserved segments of the population, and to effectively improve their health and nutrition status; (c) focus on women (in particular pregnant and lactating women) and children under five years of age; (d) ability to strengthen the role and capacity of community groups, NGOs and municipalities to plan and implement health projects and programs; and (e) capacity for continuity of sub-project benefits once SIMAP's financing ends. General Eliibtility Criteria for Health and Nutrition Sub-Projects 2. Sub-project categories in health would include: (a) Primary health care infrastructure (i) Construction, expansion or rehabilitation of district hospitals (maternal and child health outpatient services only), health centers and health post. Sub-project proposals that include civil works need also to involve the supply of furniture and basic equipment. In addition, in areas where malnutrition rates are high, the proposal needs to include a food supplementation component coupled with nutrition education and growth monitoring activities. Improvements in water and sanitation systems of the health facility need also to be included in the request. Future staffing and recurrent costs of the rehabilitated, expanded or newly constructed infrastructure MIst be insured. - 58 - ANNEX 6 Page 2 of 6 (ii) Supply of furniture and basic equipment for district hospitals (maternal and child health outpatient services only), health centers and health posts. (b) Supplies and drugs for primary health care services (i) basic medical supplies (in accordance with MOH guidelines)l; (ii) essential drugs (in accordance with MOH guidelines and latest WHO list)-; (iii) non-essential drugs considered necessary to prevent, treat and control prevailing health problems in the area; (iv) chemicals and supplies for the control of vectors responsible for endemic diseases (e.g. malaria, dengue); and (v) equipment and supplies for health information and education programs. (c) Health Outreach Programs Mi) per diem and transportation costs- for primary health care personnel based in district hespitals, health centers and health posts to carry out bi-weekly visits to outreach areas and provide immunization, pre-natal and post-natal care visits (as well as nutritional surveillance); and (ii) bags and equipment for personnel assigned to outreach visits. 3. In health sub-projects, SIMAP does not finance: (a) civil works for hospitals other than those involving maternal and child health outpatient services; 15, (b) furnishing other than basic furnishings; 1/ A complete list of basic supplies per level of care (including unit costs) should be kept in SUWAP's database. This list should be made available to the requesting agency for the preparation of sub-project proposals. LI The list has been developed by SIHAP and Includes about 20 essential drugs.. 31 Per Diem and transportation unit costs need to be determined by SIMAP and introduced in their unit costs data base. - 59 - Page 3 of 6 (c) motor vehicles; (d) recurrent costs of the sponsoring agency, other than those generated directly by the sub-project; and (e) land. 4. Sub-project categories in nutrition would include: (a) Food Supplementation Programs The sub-project proposals should be compatible with the following criteria: (i) all pregnant and lactating women attending pre- and post- natal control visits would receive 2 Kg. of milk and 2 Kg. of rice every month; (ii) all infants from six months to two years of age would receive 2 Kg. of milk every month; (iii) malnourished children (severe and moderate malnutrition) from two to five years of age would receive 2 Kg. of milk and 2 Kg. of rice; iv) food should be purchased at the local level-; (v) the proposals need to indicate the availability of qualified suppliers in the area, and local shopping procedures with quotations frbm at least two suppliers need to be followed; (vi) costs of hiring a person responsible for coordinating the purchase and distribution of food are eligible for financing; and (vii) all proposals including a food supplementation component need to include nutrition surveillance activities (involving the supply of scales and growth monitoring charts) and nutrition education activities (i.e. promotion of breastfeeding, adequate utilization and handling of food, information about diseases associated with malnutrition). The proposal needs to include a complete description, methodologies and schedules for the implementation of these activities. 41 In very remote areas where food might not be available locally, the sub-project could include transportation costs. - 60 - ANNEX 6 Page 4 of 6 General Eliibility Criteria for Day-Care Sub-Projects 5. Sub-Project categories in day-care would include: (a) construction, rehabilitation, expansion and equipping (including growth monitoring equipment) of day-care centers; special attention should be given, particularly in the case of construction of a new center, to the sustainability of day-care center at the end of SIMAP's financing (user charges, other sources of financing should be closely examined); (b) construction, rehabilitAtion, expansion and equipping of kitchens and dining rooms (or serving areas) and food storage areas; (c) food (one or two meals) for all children under five years of age attending the day-care centers according to pre-defined menus designed by the Guyana Agency for Health Sciences Education, Environment and Food Policy (GAHEF) (to ensure sustainability, beneficiary contributions should account for at least 50 pei4ent of the value of the food); (d) every child entering the center should have a health check-up, including growth monitoring and immunization (if necessary); and (e) nutrition education for parents, particularly for those with malnourished children. Genera E1-igibility Criteria for Water and Sanitation Sub-Projects 6. The following types of sub-projects would be eligible for SIMAP financing: (a) Water Supply: construction, expansion or rehabilitation of public water supply systems (standpipes) or the extension of domicile water supply systems to provide a public water supply system; and rehabilitation and reinforcement of domicile water supply networks only for collectives of less than 5,000 inhabitants. The above types of sub-projects must comply with the following conditions: (i) construction or expansion of domicile water supply systems are not financed unless the expansion is initially intended to provide a public water supply system (standpipes); (ii) for domicile water supply systems, rehabilitation is eligible only for small scale networks (covering less than 5,000 people); (iii) for the consG-ruction or expansion of non-domicile water supply systems, the source capacity must be insured; - 61 - AMNEX 6 Page 5 of 6 (iv) construction or expansion of non-domicile water supply systems, the main pipe must be dimensioned to provide future domicile supply; and (v) for the construction, expansion or rehabilitation of any water supply system, the community must have already established a committee able to manage an'l maintain the existing or proposed system. (b) Sanitation: construction or rehabilitation of water and sanitation facilities for public schools, health centers, markets and public toilets; and construction of pit latrines. The above types of sub-projects must comply with the following conditions: (i) construction or rehabilitation of water and sanitation facilities in public schools, markets or public toilets are eligible for SIMAP financing, if future operation and maintenance of the infrastructure is ensured; 'ii) public toilets or facilities for markets must be located in urban or rural areas where a domicile water supply system exists. In addition, the proposal must provide for security measures to avoid vandalism or theft (e.g. attendants responsible for supervision); (iii) sub-project proposals for latrines must include a training program for the beneficiaries; and (iv) for family latrine proposals, a maximum of 10 VIP latrine units will be provided per village and the sponsor must demonstrate that the beneficiaries are the poorest members of the community. (c) Stormwater Drainage: construction or rehabilitation of residential drainage systems in densely populated rural areas including the rehabilitation or replacement of associated structures such as culverts. The above types of sub-projects must comply with the following conditions: (i) tertiary or roadside drains shall be provided to every houselot; (ii) secondary or sideline drains shall be provided according to local practice to collect discharge from the tertiary drains; (iii) reinforced concrete road culverts shall be ptovided where secondary or sideline drains are crossed by existing vehicular access; (iv) where possible, existing culverts and bridges providing houselot access shall be retained; - 62 - ANNEX 6 Page 6 of 6 (v) provision shall be made to provide 25X of houselots with new footbridge access and lOX with new road access; (vi) where drain sections are unstable or insufficient reserve is available, drains shall be reveted; (vii) all spoil excavated from drains shall be removed from site and the formed section sprayed with an approved herbicide to a distance of two yards from the excavation; (viii) tertiary drains shall be designed for a peak run off rate of 1.17 inches per hour (assuming that drains are to be 2 ft deep with a 2 ft bed width and 1 in 1 side slopes); and (ix) secondary or sideline drains shall be designed for a run off of 0.74 cusecs per acre when controlled by a tidal sluice and 0.154 cusecs per acre when pumped (assuming that drains are to be 4 ft deep with a 3 ft bed and a 1 in 1.5 side slope). igjJaJle-Organizations 7. The following types of organizations would be eligible for SIMAP financing of health and nutrition sub-projects: (a) decentralized public health care institutions: district hospitals, health centers and health posts; (b) NGOs and church groups; (c) municipal governments; and (d) all of the above and community groups with no NGO legal status If sponsored by PAHO, UNICEF or UNDP. 8. The following types of organizations would be eligible for SIMAP's financing of water and sanitation projects: (a) municipal governments and Regional Democratic Councils when the Ministry of Public Works and Regional Development guarantees through GUYWAa the operation and maintenance of the systems belng upgraded; and (b) NGOs and church groups when the proposal specifies clearly what mechanisms will be established to guarantee the operation and maintenance of the systems being upgraded. 5L Or the Cuyana Sewerage and Water Comissioneres-GSwC- I.n Georgeton. - 63 - ANILEX 7 Page 1 of 4 GUYANA SIMAP/HEALTH. NUTRITION. AND WATER AND SANITATION PROJECT SINAP FRANEWORK FOR PHASE-OUT PLAN The Context of SIMNP within Government Strategy 1. SIMAP was launched in early 1989 to address the social costs of the Economic Recovery Program (ERP) undertaken by the Government of Guyana. This program sought to reorient the role of the state in the economy, to address severe external and internal imbalances, and to promote economic growth. It was recognized from the outset that policies to liberalize trade and prices, achieve a realistic exchange rate, and reduce government subsidies would have negative short-term impacts on the welfare of many Guyanese. 2. SIMAP was therefore designed as an emergency mechanism to complement the ERP. The first phase of SIMAP sought an immediate response to economic hardships through an income transfer scheme to provide income supplements to vulnerable groups, defined as old age pensioners, pregnant and lactating mothers and children under five years old. The second phase of SIMAP has involved the financing of sm&ll-scale projects to assure essential investments in infrastructure and social services at a time of falling government resources, thereby creating temporary employment and creating a safety net of primary health care and nutrition supplements to the most vulnerable groups. 3. SIMAP was designed by the Government as an emergency stop-gap mechanism which would be phased out. Due to its emergency nature SIMAP was granted semi-autonomous status from the public sector structure and was exempted from several regulations such as having to adhere to the civil service salary scale. Moreover, many of SIMAP's responsibilities in principal should be carried out by the line ministries or local governments including the financing of rehabilitation of public infrastructure, such as roads, schools and water supply systems, and the provision of inputs to the public health system. the Phasing Out of SIMEl 4. Assuming the success of SIMAP in carrying out these functions, two questions arise. First, what are the justifications for the phasing out of SIMAP? And second, what are the mechanisms for transferring the responsibilities temporarily assumed by SIMAP back to the appropriate government agencies? To respond to the first question, the role of SIMAP must be seen in conjunction with other elements of the Government's overall strategy. While SIMAP is to address the short-term social costs of the economic policies being implemented by the Government, these economic measures are designed to deliver benefits in terms of increased production and - 64 - Page 2 of 4 productivity, increased economic opportunities and a more solid fiscal position. Coupled with these macroeconomic measures, the Government is instituting a broad policy of reforming the public sector, including privatization of many state enterprises, a recent restructuring of public agencies scaling down from eighteen ministries to eleven, and longer range policies for increasing public revenues and adjusting public sector salary scales and incentives to respond to the pervasive manpower shortages. 5. In addition to these medium-term policies which will limit the need for an agency such as SIMAP, SIMAP itself is ill-suited to function beyond its emergency scope. As an emergency institution SIMAP can provide stop-gap financing, however over the longer term SIMAP will duplicate functions of other government agencies. SIMAP has a project-driven approach which allows for the rapid flow of public investment during a time of economic crisis. However, for efficient public sector planning and investment and to implement sector strategies, a program approach will be necessary. For example, SIMAP will finance short-term stocking of essential drugs and supplies in health centers. To assure sustainability of these services, the Government (through the Ministry of Health) will need to consolidate a program for essential drug distribution which includes appropriate user fees, logistical systems, monitoring and supervision mechanisms on a national scale. SIMAP does not have the mandate or the capacity to design and carry out these longer-term policies. 6. Given the need for a phase-out of SIMAP, the second question of how this is to be done is best analyzed sector by sector. IDA support to SIMAP focuses on health, nutrition and water and sanitation; the transferring of SIMAP activities in these sectors are foreseen as follows: Health Activities. SIMAP's support in stabilizing the delivery of primary health care services in the short-term will be backed up in particular by two programs to be implemented in the Ministry of Health. The IDB has approved a US$31 million project to rehabilitate the Georgetown Hospital, improve the supply of essential drugs to the health system and improve the management of the Ministry of Health. The IDA support to SIMAP includes the preparation of a complementary investment project through the MOH to ensure the sustainability of the primary health care system. Nutrition Activities. SIMAP will finance emergency nutrition projects which will provide a valuable pilot experience for the shaping of a national nutrition program. At the end of 1994, the Government (through SIMAP with IDA technical assistance) will assess: (i) the general country situation (agricultural production, income levels, price indexes and prevailing malnutrition rates); and (ii) the impact and cost- effectiveness of SIMAP's efforts in nutrition. Based on this analysis, a national nutrition program will be designed taking into account the availability of food donations and the absorptive capacity of the public sector budget. Preparation of the proposed IDA health project will include support in the implementation of this national strategy. - 65 - QAZ Page 3 of 4 Water and Sanitation Activities. The bulk of SIMAP's efforts in this sector involve financing small projects in the repair and rehabilitation of existing systems. These are activities that for lack of manpower and financing have been left unattended by municipal and regional governments and the national water company (GUYWA). To address longer- term sector issues, the IDB will finance a project which will provide institutional strengthening to GUYWA, review national water tariff policies and cost recovery mechanisms and prepare a master plan for water supply, sewerage and drainage for the greater Georgetown area and identify investment needs for regional schemes. The master plan is expected to be in place by the end of 1993. General Considerations 7. The strategy outlined above assures that the responsibilities temporarily undertaken by SIMAP will be transferred back to sector ministries more able to continue them on a long-term basis. However, the plan for the phasing out of SIMAP should also consider how to take advantage of the rich experience SIMAP will accumulate in such areas as project appraisal and execution, management information systems, the use and control of private sector contractors, the experience of working with grassroots organizations and NGOs and other areas of expertise which will evolve throughout the life of SIMAP. S. As part of its wrap-up activities, SIMAP will systematize the lessons learned from its experience and carry out a program for disseminating this information. Such a program could include written materials, seminars, short-term in-service training of public sector staff or other appropriate mechanisms to be identified by the Government. 9. In terms of what happens to SIMAP itself, the staff, office equipment, computers and vehicles, the Government will need to review this issue as part of the phase out plan. A number of alternatives can be imagined: (i) SIMAP is closed, the staff is disbanded to follow a natural process of integration into the public and private sectors and the physical assets are distributed to other public agencies (or channelled into the medium- term follow-on investment projects planned by the international agencies financing SIMAP); (ii) part of the SIMAP staff and equipment is transferred to the State Planning Agency to assist line ministries in screening project proposals and identifying international donor financing (to capitalize on SIMAP's experience with project appraisal and its contacts with the international donor community); and - 66 - ANNEX 7 Page 4 of 4 (iii) SIMAP evolves into an agency of the Government to support grassroots initiatives through the financing of small- scale self-help projects, filling in gaps of coverage by the line ministries with activities carried out by NGOs and community groups. 10. At this point, these alternatives are purely speculative. In addition, other ideas will surely emerge as SIMAP evolves. Preparation of a Phase Out Plan for SIMAP 11. The Government must present a SIMAP phase out program to its financiers which elaborates on the following points: (i) a detailed plan for the transfer of SINAP responsibilities back to the corresponding government agencies, including an evaluation of these agencies' capacities to reabsorb these responsibilities; (ii) a program to systematize and disseminate the lessons learned from the SIMAP experience; (iii) a plan for the closure/transformation of SIMAP itself; and (iv) a timetable for the phase out of SIMAP. - 67 - ANNEX 8 GUYANA SIMAP/HEALTH. NUTRITION. AND WATER AND SANITATION PROJECT KEY INDICATORS IN THE SIMAP MANAGEMENT INFORMATION SYSTEM The management information system established by SIMAP will track the following basic information: Finance/Administration Resources Committed to SIMAP, Amount and Source Administrative Costs, by Type (salaries, transportation, office overhead, etc.) Technical Assistance, Amount Committed and List of Contracts Disbursements, Amount by Financing Source Sub-Projec t Information Sub-Project Cycle: Date of Sub-Project Registration by SIMAP Date of Evaluation Site Visit Date of Approval By the Board of Directors Date of Commencement of Implementation Date of Sub-Project Conclusion Average Time Elapsed in Each Phase Basic Sub-Project Data: Project Name Project Code Number (reflecting category/sub-category/ID #) Name of Sponsoring Agency Name of Supervisor, if applicable Location of Project (region, rural/urban, location name) Poverty Index (indicator may vary by type of sub-project) Total Project Cost Amiount Financed by SIMAP Counterpart Financing, by Source and Amount Estimated Duration of Execution Physical Targets (e.g., square meters of construction, amount of water delivered/day, number of latrines, number of nutrition supplements/meals, number of health posts equipped, etc.) Estimated Cost per Physical Unit Estimated Number of Beneficiaries Estimated Cost Per Beneficiary Amount of Disbursements to Sub-Project Percentage of Sub-Project Executed Percentage Delay in Sub-Project Execution Changes in Contract Amount During Execution -68 - ANNEX 9 Page 1 of 5 GUYXANA SIVAP/EHILTH. NUTRITION. AND WATER AND SANITATION PROJECT IMPLEMENTATION PLAN AND REVIEW CRITERIA SIMAP's annual review will be an essential instrument in the process of planning and implementation of project activities and will constitute the key monitoring tool for the proposed project. During the review process, project implementation progress indicators as well as technical assistance activities and studies will be reviewed against quantitative targets defined below (see Part A). These targets were agreed during negotiations and included in a supplemental letter to the Development Credit Agreement. In addition to evaluating progress in reaching the targets defined in the implementation plan, the review process will assess progress related to a number of project areas (see Part B). PART A - IMPLEMENTATION ILAN L. KeY Monitoring Indicators tOuantLtative Targets) Schedule of Sub-grojects -o be implemented 1991-95 (Part B of the Project) 1. Under the HealthZ/NtrJitn Sub-Component: June 1991-June 1992: 4 Sub-projects' July 1992-June 1993: 20 Sub-projects July 1993-June 1994: 30 Sub-projects July 1994-June 1995: 20 Sub-projects 2. Under the DAX Ce Sub-Component: June 1991-June 1992: 7 Sub-projects' July 1992-June 1993: 4 Sub-projects July 1993-June 1994: 2 Sub-projects July 1994-June 1995: 2 Sub-projects Already under implemeneetion with financlng of PPP P680-GtIJ. Sao SFoonote IL - 69 - ANNEX 9 Page 2 of 5 3. Under the Water and Sanitation Sub-Component: June 1991-June 1992: 2 Sub-projects (Water Supply) 60 Sub-projects (Basic Sanitation) 1 Sub-project (Drainage)"' July 1992-June 1993: 7 Sub-projects (Water Supply) 30 Sub-projects (Basic Sanitation) 7 Sub-projects (Drainage) July 1993-June 1994: 15 Sub-projects (Water Supply) 20 Sub-projects (Basic Sanitation) 10 Sub-projects (Drainage) JuLy 1994-June 1995: 10 Sub-projects (Water Supply) 20 Sub-projects (Basic Sanitation) 10 Sub-projects (Drainage) Number of Beneficiaries Covered Under the Food SuonleMentation-Scheme (Part B of the Project)4/ 4. June 1991-June 1992: 1,600 (children 6 months-2 years) 400 (malnourished children 2 years-5 years) 800 (Pregnant and Lactating Women) July 1992-June 1993: 9,600 (children 6 months-2 years) 2,400 (malnourlshed children 2 years-5 years) 4,800 (pregnant and lactating women) July 1993-June 1994: 20,000 (children 6 months-2 years) 5,000 (malnourished children 2 years-5 years) 10,000 (pregnant and lactating women) July 1994-June 1995: 20,000 (children 6 months-2 years) 5,000 (malnourished children 2 years-5 years) 10,000 (pregnant and lactating women) aI soe Footnote IL 4 All proprm vill hAve at least a duration of 24 months. - 70 - ANNEX 9 Page 3 of 5 II. Technical Assistance Activities and Studies Institutional Development Component (Part A of the Project) 5. Strengthening Administrative and Accounting Systems: Consultant (1 man-month) to complete mission by September 30, 1992. Report with findings and recommendation to be sent to IDA no later than October 31, 1992. 6. Management Information Systems: Consultant(s) (3 man-months) to complete missions by November 30, 1992; November 30, 1993; and November 30, 1994. Consultant(s) (24 man-months) to prepare progress/system implementation reports no later than November 1, 1992; November 1, 1993; and November 1, 1994. 7. Poverty Targeting: Consultant (1 man-month) to complete mission by January 31, 1993. Report with findings and recommendations to be sent to IDA no later than February 28, 1993. 8. Unit Cost Data Base: Consultant (1 man-month) to complete mission by November 30, 1992. Report with findings and recommendations to be sent to IDA no later than December 31, 1992. 9. Operations Manual: Consultant(s) (3 man-months) to complete missions by February 28, 1993; February 28, 1994; and February 28, 1995. Report with findings and recommendations (and possibly changes to be introduced in the operations manual) to be sent to IDA no later than March 31, 1993; March 31, 1994; and March 31, 1995. 10. Food Supplementation: Consultant(s) (3 man-months) to complete missions by September 30, 1992; September 30, 1993; and September 30, 1994. Report with findings and recommendations to be sent to IDA no later than October 31, 1992; October 31, 1993; and October 31, 1994. Consultant(s) (26 man-months) to prepare bi-annual reports on implementation aspects and evaluation of impact of food supplement program. 11. Sub-Project Implementation: Implementation Specialist(s) should be in Guyana no later than October 1992 (12 man-months) to assist SIMAP in reviewing sub-project implementation arrangements and overall appropriateness of SIMAP promotion, appraisal and monitoring procedures. 12. Phase-Out Plan: Consultant(s) (2 man-months) to complete missions by December 31, 1994; and December 31, 1995. Reports including a detailed implementation plan and progress in execution of the phase-out plan should be submitted no later than January 31, 1995 and January 31, 1996, respectively. - 71 - ANNvEX 9 Page 4 of 5 Health Policy DevelOM e2nt GOmMonnt (Part D of the Project) 13. Analysis of opidemiological profile, access to and coverage of health services; analysis of health infrastructure, maittenance systems, medical equipment, drugs and supplies, and transportation; and analysis of organizational and staffing arrangements and management systems: Technical assistance, and studies to be completed and submitted to IDA no later than December 31, 1993. 14. Definition of health priorities and target groups; institutional, staffing and management arrangements; and definition of a health sector investment program: Technical assistance and studies to be completed and submitted to IDA no later than June 30, 1994. 15. Definitlon of a solid portfolio of projects in the health sector for external financing: Technical assistance and studies to be completed and submitted to IDA no later than December 31, 1994. PART B - REVIEW CRITERIA (1) Efficieney of SIMAP Operations and SIMAP Sub-Projects (a) number and amount of sub-projects approved per week; (b) number of sub-projects in execution; (c) amount of monthly disbursements; (d) rate of delays in sub-project execution; (e) administrative costs as a percentage of total SIMAP budget; (f) number of physical units completed (i.e., health centers rehabillitated, water supply or drainage systems expanded and/or rehabilitated, quantities of food delivered); (g) number of beneflciaries reached; (h) geographical distribution of sub-projects; and (i) cost per unit delivered and cost per beneficiary. (2) Procurement and Audits (a) findings of the procurement auditor for shopping and direct contracting procedures; (b) random ex-post review of contracts for works under US$100,000 equivalent purchased under LCB and of contracts for works and goods purchased under shopping and direct contracting procedures; and (c) annual audit reports. - 72 - Page 5 of 5 (3) Administration and Operational Procedures (a) staffing and compensation package of SIMAP staff; (b) sub-project promotion procedures; (c) sub-project appraisal procedures; (d) sub-project supervision procedures; (e) Board's role and functions; and (f) operations manual. (4) Technical Assistance (a) nature, scope and recommendations of technical assistance received during the previous year; (b) program of technical assistance for the following year; and (c) final terms of reference for scheduled technical assistance. (5) Budget and Annual Program (a) SIMAP's budget; and (b) SIMAP's annual program (this should include the identification of a portfolio of solid sub-projects expected to be financed during the following year). (6) Phase-out Plan and Development of Policy Framework for the Health Sector (a) programs and actions undertaken by Government to guarantee sustainability of sub-project activities carried out by SIMAP and to guarantee a smooth institutional and programmatic transfer of responsibilities to permanent Government agencies; (b) consultant recommendations for the development of an institutional and policy framework for the health sector; (c) program for phase-out activities as well as for policy development of the health sector to be undertaken the following year; and (d) project proposals in the health sector for external financing (last two years of the project); (7) Monitoring and Evaluation (a) implementation of the LSMS component; (b) targeting mechanisms; (c) results of LSMS survey and assess impact of SIMAP Program (fourth year of the project); and (d) results of the malnutrition survey. - 7N3 - NEX-0 GUYANA SIMAP/HEALTH. NUTRITION. AND WATER AND SANITATION PROJECT DETAILED PROJECT COSTS Local>' , ^' ' ' Foreign ' TotAi 1A Lo0al For tein -Totl % Amount; % -mont U Total Amount ' ' o ;"'; Mililone of GuYS millions of US$ . Health and NutrIiton -civil works (rehab. of health centers) 81e60 eo.0 20.40 20.0 102.00 i.3 0.68 80.0 0.17 20.0 0.85 7.3 non-medlcal equipment. supplies & furniture 12.00 50.0 12.00 50.0 24.00 1.7 0.10 50.0 0.10 50.0 0.20 1.7 medical equipment suppilee& drugs 39.60 25.0 118.80 75.0 158.40 11.3 0.33 25.0 0.99 75.0 1.32 11.3 - Food 240.00 100.0 0.00 0.0 240.00 17.1 2.00 100.0 0.00 0.0 2.00 17.1 Subtotal Health & NutrItion 373.20 71.2 151.20 28.8 524.40 37.4 3.11 71.2 1.28 28.8 4.37 37.4 2. Day-Care centers -lvil works 22.08 80.0 5.52 20.0 27.60 2.0 0.18 60.0 0.05 20.0 0.23 2.0 - equipment 16.80 70.0 7.20 30.0 24.00 1.7 0.14 70.0 0.06 30.0 0.20 1.7 food 89.60 100.0 0.00 0.0 89.60 5.0 0.58 100.0 0.00 0.0 0.58 5.0 Subtotal Day-Car. Centers 108.48 89.5 12.72 10.5 121.20 8.8 0.90 69.5 0.11 10.5 1.01 68. 8. Water & Sanitation watertupply 108.00 50.0 108.00 50.0 218.00 15.4 0.90 50.0 0.90 50.0 1.80 15.4 baalc anitation 81.20 85.0 10.80 15.0 72.00 5.1 0.51 85.0 0.09 15.0 0.60 5.1 wastewater dralnage 57.60 40.0 88.40 80.0 144.00 10.3 0.48 40.0 0.72 80.0 1.20 10.3 Subtotal Water & Sanitation 228.80 82.5 205.20 47.5 432.00 30.8 1.89 52.5 1.71 47.5 3.80 30.8 4. Technical Assistance to partcipating SAs 18.80 70.0 7.20 30.0 24.00 1.7 0.14 70.0 0.06 30.0 0.20 1.7 Subtotal SMAP Sub-projote 728.28 84. 375.32 34.2 110.60 78; ..0.4< 85* 3.1a .. 34.2 #.0 d --78 I.l INSTITUTIONAL SUPPORT ___;_-____:_. 1 SIMAP Admlnlstrtaton -salaes 48.00 1000 0.00 00. 48.00 3.4 OAO 1000 0.00 0.0 0.40 3.4 travel, training 8.00 50.0 8.00 50.0 12.00 0.9 0.05 50.0 0.05 50.0 0.10 0.9 operating expenditures 42.00 100.0 0.00 0.0 42.00 3.0 0.35 100.0 0.00 0.0 0.35 3.0 Subtotal AdministratIon 98.00 94.1 8.00 5.9 102.00 7.3 0.80 94.1 0.0b 5.9 0.85 7.3 2. Equlpment. vehicles and maintenance equipment 0.00 0.0 7.20 100.0 7.20 0.5 0.00 0.0 0.08 100.0 0.06 0.5 -vehicles 0.00 0.0 21.60 100.0 21.80 1.5 0.00 0.0 0.18 100.0 018 1.5 - malntenanG4 3.60 100.0 0.00 0.0 3.80 0.3 0.03 100.0 0.00 0.0 0.03 0.3 Subtotal EquIpment. vehicles and malntenance 3.80 11.1 28.80 88.9 32.40 2.3 0.03 11.1 0.24 88.9 0.27 2.3 3. Technical Assistance 40.50 45.0 49.80 55.0 90.00 6.4 0.34 45.0 0.41 55.0 0.78 8.4 Subtotal SIMAP fnst. 8upport 40.10 62.;4 ao0 a7.0 224A0 18.0 t.17 0.4 :' .. 1* 1 Ill. LaMa a MORBID. SURVEY. E. I. S0.0 100.0 0t00 00. 9.60 0.7 008 100.0 000 00 0.08 0.7 2. Equlpment 0.72 20.0 288 60.0 3.60 0,3 001I 20.0 0.02 o0o0 0.03 0.8 8. Operational Expenditures 6.40 100.0 0.00 0.0 8.40 0.6 0.07 100.0 0.00 0.0 0.07 0.6 4. Technical Aislastnce 2.88 20.0 11.52 80.0 14.40 1.0 0.02 20.0 0.10 60.0 0.12 1.0 SubtotalLSMS&111torb.Survey 21.60 00.0 14.40 40.0 30.00 2.e "a8 e0o0 o.1t2 40.0 . 0.0 :....2.3 IN. HEALTH SECT. POLICYEVT, ===_=_= 1. TechnIcal AssIstance 8.40 20.0 33.60 80.0 42.00 3.0 0.07 200 0.28 80.0 0.35 3.0 Subtotal Health S8ct. PalIcy Devp 8.40 20.0 33.80 e0.0 42.00 8.) 0.07 2c.0 06 0- °- 3 ~~ 895.30 63.61 806*2 88.2 1404.00 ~~~~100.0 7.40 863.8 4.24;. 36*4 *: 1 .70..... i.. - 74 - ANNEX1I SIMAPIHEALUH. NUTRMON. AND WATER AND SANITATION PROJEe T FINANCING PLAN (USS Million) .~~~~~~~~~~~~~~~~~~~~~~~~~~~... . .., , sj . > Healfth & Nutiion 0.08 0.10 4.19 4.37 Day Care nters 0.10 0.27 0.64 1.01 Water and Santation 0.2D 0.20 - 3.20 3.60 Technical Assistance - 0.20 0.20 to Patcipating SAs Sub-Total, SIMAP Subprojects 0.38 0.57 0.00 8.23 9.18 ....................... Acdninistratlon 0.15 - 0.15 0.55 0.85 Equipment, Vehicles and Maintenanoo - - - 0.27 0.27 Technical Assistane - 0.15 0.60 0.75 Sub-Total, SIMAP Insttutional Suppof 0.15 - 0.30 1.42 1.87 Salaes - - 0.08 0.08 Equipment , * 0.03 0.03 Operating Expenditures * 0.07 0.07 Technlcal Assistance - 0.12 0.12 Sub-Total, LSMS & Morb. Survey . * 0.30 0.30 f% ,,)th Sector ,oly . '-:- 's t. .. .- .. . Technical Assistance - 0.35 0.35 Sub-Total, Health Sector Policy Devpt. 0.35 0.35 W E A L ......... i . i .... >>is.: S . s . ........... .. ... ..... ... . % of TOTAL 4.5 4.9 2.6 88.0 100.0 f ANNEX 12 -75- PageI of 2 GUYANA SIMAPIHEALTH. NUTRMON. AND WATER AND SANITATION PROJECT Table 1: DISBURSEMENT FORECAST IDA Fiscal Year and Semester 1st (July '91 - Dec '91) 0.30 0.30 2.9 1 2nd (Jan '92 - June '92) 0.45 0.75 7.3 2 ist (July '92- Dec '92) 0.90 1.65 1W.0 3 2nd (Jan '93 - June '93) 1.25 2.90 28.2 4 1st (July '93 - Dec '93) 1.40 4.30 41.7 5 2nd (Jan '94 - June '94) 1.40 5.70 55.3 6 1st (July'94 Dec'94) 1.40 7.10 68.9 7 2nd (Jan '95 - June '95) 1.35 8.45 82.0 8 lst (July '95 - Dec '95) 0.95 9.40 91.3 9 2nd (Jan '96 June '96) 0.90 10.30 100.0 10 Closing Date: June 30, 1996 at PPF Resources only bJ Special Account Included 76- ANNEX I Page 2 od2 G_UYAN SIMAP/HEALTH. NUTRMl1ON. AND WATER AND SANITAlTON PROJECT Table 2: DIS&URSEMENTALLOCA;TONS m ,~~~~~~~~~~~~~...... .., ,...,. Category (a) CMi Works 690,000 95% of eligible expedtures (b) Non-medical Equipmet 110,000 Supplies & Furnture (c) Medical Equipment 330,000 Supplies & Drugs (c) Food 2,150,000 etr..rs ...... (a) Cmi Works 140,000 80% of eligibl expenditures (b) Equipment 12D,000 (c) Food 450,000 0. Sub-aDjt for Wter 8 0antadon .. .. : -:: .-:: . (a) Water Supply 1,600,000 95% of eligible expenditures (b) Basic SanitatIon 310,000 (c) Wastewater Dranage 960,000 4. TechnIcl A tac toParIpatin g SA . .: . . ...;.:. (a) Tecnical Assistanc 190,000 100% of eligible expenditres 5.6 SIMAP tnstitutioat Support (a) Salaries, Travel, Training, 510,000 10096 of eligible expenses and Operating Expenses (b) Equipment, Vehicles and 150,000 MU Intenanoe (c) Technical Assistance 420,000 100% of eligible expendtures for consultants' services, rvel, expenses and per diem 6 $MS '&Morbidity ...:y (a) Salares 80,000 100% of eligible expenditures (b) Equipment 30,000 (c) Operational Expenditures 70,000 (d) Technical Assistance 100,000 100% of eligible expenditures for consuitants' services, travel, expenss and perdbm (a) Achnial Assistance 350,000 100% of elible expenditures for consulta' servis, travel, expenses and oer dim ....... .. 750,000 . 100% of eligible expexaures 790,000 Total 10,300,000 . - 77 - ANEX 13 siNPEALUTN. RUTEITION. AlD UATER AMe SANITATION PRQYECT INPLEJENTATION SCNHULE ESTINATED AMMJA COUAM flu OT-ER PANNTS (USS million equivalent) Pre- Project Years Total Project Eloments Project 1 2 3 4 Pay)ent RemArks Cr2dit T1f1na SiginEffect/Close ** vorks Heatth FacfLities 0.20 0.20 0.20 0.15 0.75 Shopping Day Care Centers 0.04 0.05 0.05 0.04 0.18 Shopping Construction xxxxxxxxxxxxxxxxxxxxxxxxx Water Supply Prequal/DId/Award ... ... ... ....... Construction 0.30 0.70 0.50 0.30 1.60 LCB Waste Water Drainage 0.20 0.30 0.30 0.30 1.10 LCD/Shopping .)O(x....Kxx.... x.... xxx Sanitation 0.05 0.20 0.15 0.10 0.50 Shopping x xx x xxxx xx x xxxx xxxxxx xx xx Medical Eq./Drugs 0.2_ 0.50 0.50 0.07 1.32 Shopping Non-Medical Eq/Supplies 0.10 0.10 0.10 0.08 0.38 Shopping HIS/Vehicles 0.05 0.05 0.02 0.12 Shopping xxx... xxx.....xxxx... xxxx Food 0.65 0.65 0.65 0.63 2.58 Shopping xxxxxxxxxxxxxxxxxx ConsuLtorcRes Procurement Agency/ Audit Firm 0.06 0.06 0.06 0.06 0.24 Precondition xxxxxxxxxxxxxxxxxxxxxxxxx Technical Assistnce 0.25 0.26 0.26 0.26 1.03 xxx .... xxxx.... xxx .... xxx Slteresea/fer.Exaenses SINAP Agency 0.20 0.20 0.20 0.20 0.80 SalarIes xxxxxxxxxxxxxxxxx Surveys 0.04 0.04 0.04 0.03 0.15 xxx.... xxx .... xxx.... xxxx "Ujietemmu PPF RffinancWng 0.75 0.75 xxxx Totals 3.14 3.31 3.03 2.22 11.70 (IDA Financed) (2.90)(2.80) (2.75) (1.65) (19.30) - 78 - ANNEX 14 Page 1 of 2 GUYANA SIMAPLHEALTH. NUTRITION. AND WATER AND SANITATION PROJECT SELECTED DOCUMENTS AND DATA AV4IIABL IN THE PROJECT FILE A. Selected Reports and Studies Related to the Sector A.1 Guyana Country Program 1990-94 Plan of Operations, United Nations Children Fund, 1989. A.2 A National Food and Nutrition Policy for the Cooperative Republic of Guyana, The Guyana Agency for Health Sciences Education, Environment and Food Policy (GAHEF), May 1991. A.3 Targeting Vulnerables in Guyana, Deo Rampraskash, UNDP Consultant, October 1990 and October 1991 (Update). A.4 Health Conditions in Guyana, Ministry of Health with PAHO/WHO, J-une 1989. A.5 Guyana-Health Care II Project, Project Document Inter-American Development Bank, 1989. A.6 An Environmental Profile of Guyana and a Programme for Environmental Management, The Guyana Agency for Health Sciences Education, Environment and Food Policy, Nov. 1990. A.7 Guyana, List of Projects for External Financing, 1992-95, Document of the World Bank, June 7, 1991. A.8 Guyana A Third Technical Assistance Project, World Bank, June 7, 1990. A.9 Project Proposal Monitoring and Improving the Nutritional Status of Pre-School Children in Guyana. MinLstry of Health with PAHO/WHO, October 1989. A.10 Guyana-Second Structural Adjustment Credit, World Bank, June 7, 1990. A.ll Guyana Nutrition Education Community Project, the Guyana Agency for Health Sciences Education, April 1991-March 1992. A.12 Food Supplementation in Guyana, Fernando Vio, October 1991. -79 - ANNEX 14 Page 2 of 2 A.13 "Health and Nutrition situation in Guyana, Back-to-Office Reports by Fernando Vio, Consultant (February 1991, April 1991, June 1991 and October 1991). A.14 "Food Production, Distribution and Pricing in Guyana", Mission Report, April 1991. B. Selected ReDorts and Studies Relating to the Project B.1 "Operational Manual (lst Draft), The SIMAP Agency, August 1991. B.2 "Stormwater Drainage", M.D. Haigh (Consultant) for the SIMAP Agency, October 1991. B.3 "Water Supply and Sanitation", K.D.R. Houston (Consultant) for the SIMAP Agency, September 1991. *B.4 Sample Bidding Documents for International Competitive Bidding and Local Competitive Bidding for the purchase of Goods Under the Proposed Project", September 1991. B.5 Monitoring and Supervision of Sub-Project Implementation, Social Impact Amelioration Program, Renata Claros, July 1991. B.6 Guyana's Health and Nutrition Intervention, Fernando Vio, July 1991. C. Selected Working PaDers C. "Institutional Arrangements', Back-to-Office Reports by Julle Van Domelen, Dec. 1990, Feb. 1991, April 1991, June 1991, July 1991 and October 1991. C.2 Terms of Reference for Technical Assistance under the Institutional Development and Project Preparation Components of the Proposed Project, Fernando Vio, July 1991 and Julle Van Domelen, July 1991. C.3 List of Drugs for Local I and II Care. C.4 Implementation of an MIS System for the SIMAP Agency, Ivan Krsul, July 1991. 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