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Vol.1975/0240

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COMMISSION OPTHEEUE.OPBANCOMMUNITÏES
COM(75)642final.
Brussels,18December1975
COMMISSION REPORTTOTHECOUNCILOPTHEEUROPEAN COMMUNITIES
ONTHEIMPLEMENTATION ANDUTILIZATION OPAID
BYTHERECIPIENTASSOCIATED STATES,COUNTRIES ANDTERRITORIES
1974
C0M(75)642final

VIIIA67 /75-E
CONTENTS
Page
A* 'INTRODUCTION 1
B.UTILIZATION OFPROJECTS '' 5
I.Activities 5
1.Hospital occupancy 5
2.Other activities 6
3.Summary 6
II.Maintenance ofbuildings and equipment 8
1.Buildings 8
2.Equipaient 8
3«Programmes for the training ofmaintenance staff 9
III .Staff ofthe health units 11
1.Staff numbers 11
2.External technical assistance 12
3.Preventive medicine staff 13
IV,,Budgets ofthehealth units
1.Preliminary remarks 1*)-
2.Operating budgets 15
3.Sources ofbudget funds 17
k.Defacto balance oftheoperating budgets 18
5»Level ofopération 19
6.Structure ofthebudgets 19
7.Revenue 20
V.Médicaments " 22

II VIII/467/75-E
Page
C. •OVERALL COHERENCE OPTEEPROJECTS ATNATIONAL LEVEL 24
I.Elace oftheprojects inthedevelopment ofthehealth
infrastructure * " 24
1.Isolated projects ■ .124
2.Comprehensive projects 27
3.Complementary conditions ' - 30
4.fiummary 32
II.Personnel ■ . .. .. , .... -33
1.Doctors > 33
2,llon-physioian orancillary medical staff ,andmanagement 34
staff
3.Problem ofthe ^shortage ofmedical staff ' 34
4.Afewconsiderations onpossible measures 36
5»Summary 38
III .Health budgets atnational level 39
1.Preliminary remarks 39
2.Characteristics ofthebudgetary situation ... .39
3»External operating aid ... 43
4.Lessons drawn from analysis ofpast experience •/44
IV.Technical design 48
1.Criteria foradapting projects torequirements 48
2.Soraeconsiderations ontherequirements astotechnical
design 51
0.PROJECTS TOPROVIDE OPERATING AID 54
I.Technical assistance 5k
II.Temporary financing ofrunning costs 55
E.SUMMARY AND GENERAL CONCLUSIONS 57

III VIIIA67 /75-E
ANNEXES Page
ANNEX I -THE PR0J2CTS " ,
s Ob.jsctives ,design andgeneral results I/l
1.Projects undertaken inMadagascar 1/1
2.Health unit projects undertaken inDahomev 1/5
J.Mauritania :National hospital inNouakchott 1/7
4.Somalia :General hospital inMogadishu I/ll
5-Health unit projects undertaken in
Uppor Volta I/lk
6.Health unit projects undertaken inNiger 1/17
7-Health unit projects undertaken inCameroon 1/20
ANNEX II LIST OFPROJECTS THE UTILIZATION OFWHICH
HASBEÊN EXAMINED RI2CENTLY 11/23

k
VIII/467/75-E
INTRODUCTION
The.'purpose ofthis report ,which hasbeen drawn uppursuant toArticle *
21oftheI969 Internal Agreement onthefinancing andadministration of
Community aid ,istoprovide theCouncil oftheCommunities with informat­
ion ontheutilization of ^projects financed bytheEuropean Development
Fund 1). ■
In197^theCommission continued itswork of 'evaluating aidfinanced by
theCommunity .Theutility ofthis work ,which hasbeen carried on
continuously since 1966 incooperation with theauthorities oftherecipient
countries ,isbecoming more evident every year ,itenables theCommission
toremedy anyshortcomings intheprojects and todraw lessons for
channelling thenewaidgranted andintegrating itmore effectively inthe
development strategies applied bythevarious recipient countries .
In1974 "thoCommission concentrated onanexamination ofthe
usebeing made ofanumber ofhealth projects .Development ofthesocial
sector isone ofthe concerns ofCommunity aid and isone ofthe
priorities setinthesecond Yaoundl Convention .
Furthermore ,theCommission 'sdepartments hadalready been able inthepast
topinpoint anumber ofproblems which were affecting ,often toalarge
degree ,theutilization ofhealth projects ,thereby restricting their
effectiveness .Certain health projects have already been tfealt with in
earlier Commission reports tothaCSouofcil
./.
1)Adescription ofthewayinwhich aidisbeing implemented forms part
oftheCommission report totheAssociation Council ontheadministrat­
ionoffinancial cooperation during the197^financial year drawn up
asrequired byArticle 29ofthesecond YaoundS Convention (Document
VTII/4^9/75)•Inaddition ^anumber ofprojects theimplementation of
which wasgiving rise toparticular problems were thesubject of
communications from theCommission 'sdepartments totheEDFCommittee
during thecourse oftheyear .

-2- VIIIA67 /75-E
ontheutilization ofaid^. ' >
Ithasnowbeen possible togive greater depth anddetail tothepartial and
summary conclusions drawn r.saresult ofthese investigations#
Ithasbeen found that thedifficulties encovrtered could rarely bereduced to
asingle ,random factor which could easily becorrected bymeans ofatechnical
decision .Onthecontrary ,itappeared that inmost cases they were theresult
ofcomplex phenomena and reflected inpractice institutional deficiencies at
national level .These findings showed that itwould beuseful ,after the
completion ofasufficient number ofhealth projects ,toevaluate theresults
systematically . .•
Anexamination has therefore been carried out ofcompleted health projects which
canbeconsidered representative ofthedifferent types ofproject ,and ofthe
countries inwhich theaidsupplied bytheEDF inthehealth field was ona
particularly large scale .
' ' '" ' 2)•This report reviews twenty-four completed projects inthehealth field ,ofwhich
«
sixteen were health infrastructure projects (construction ofhospitals ,health
units ,dispensaries ,other health establishments ,etc# ).and eight' involved
temporary operating aid (technical assistance ,;financing ofoperating costs )^.
Theprojects examined concern thefollowing countries :Cameroon ,Dahomey ,
Madagascar ,Mauritania ,Niger ,Somalia andUpper Volta .The tptal amount involved
inthese' projects (30million u.a.)represents J>0%oftotal commitment ?for
health projects from theresources ofthethree Funds (101million u.a .)•
Financine décisions and disbursements (million u.a.)
Situation at31December 197^ .r -1' '
, ■EDF 1st .EDF 2nd EDF 3rd ...-,Total
Total decisions (commitments ) 581 713^ 817 .2.111
ofwhich :health^(commitments ) 50 28^ 23 101
-■ -, ;■ . ■■■ '. ' "
■health projects examined 16 12 2 30
inthis report • .■».v •
(disbursements ) /•/•
•Report references :1969 :2767/VIII/EDF/70;1970 :VIII/398/71-EDF /l;
'1971 :VIII/258/72 -EDF/C -3;1972 :VIII/702/73-C/5 ;:\r. i>
2)Seelist ofprojects inAnnex Il/23-2 1+.
3)These consecutive projects were linked toasingle hospital construction
project inSomalia (General Hospital Mogadishu ).
*0Including health campaigns andtechnical cooperation .
5)Situation attheend of1971 -

-3- . :VI11/467/75-E
Asummary oftheobjectives ,design andgeneral results -oftheprojects
examined isgiven inAnnex 1"^.Thereport itself gives asynthesis ofthe
most important points regarding theutilization oftheprojects financed by
theEDF (Chapter B).Anexamination isthen made ofthecoherence ofthe
projects generally atnational level ,i.e. theplace oftheprojects inthe
development ofhealth infrastructure ,theavailability ofstaff and ofhealth
budgets atnational level (Chapter C).Aseparate chapter isdevoted to
projects toprovide operating aid (Chapter D).Theconclusions .which .canbe
drawn from theanalysis oftheinvestments examined are set out attheend of
therelevant sections ,Xsummary andthegeneral conclusions tobedrawn from
ailthepoints raised form thefinal chapter (Chapter E)►
The content ofthis report isbased essentially on
-theevaluation missions carried outin197^inSomalia ,Upper Volta and
Niger ,.andinChad in1970 ;
-the ^valuation reports drawn upbythe .EDFDeputy Controllers in
agreement with theGovernments ofthecountries concerned :..Cameroon ,
Dahomey ,Madagascar .a$dMauritania ._
Asregards theinformation obtained ,certain methodological 'reservations oust
bemade :- ; • • ' '' ' ' •
-•The basic' statistics towhich thereport has torefer areoften '
unsatisfactory andsometimes even contradictory ? _ '/.
-Thefigmeesquoted arenotalways available forthesame .,years ,,andas
...aresult comparisons (e.g. between budgets )sometimes refer to
différent .years ;
r •. \ -■ ...... .
-Anexact definition ofwhat thefigures compared refer toisnot'
always possible . . , ,
' " ./.
1)Pages I/lto1/22. W .. - <,
2)Thevarious currencies have been converted into CFAFrancs 9attheexchange
rate inforce fortherelevant year ,tofacilitate comparisons# .

VIIIA67 /75-E
Consequently ,thefigures quoted are tobeconsidered asproviding an :
indication and inmany cases are ofvalue only forthepurpose ofcomparison .
Tosumup,itcanbeseen from thedetailed analyses that themajority of
EDF investments inthehealth sector are fully justified .All theinvestment
projects have contributed ,tovarying ,degrees ,tothedevelopment ofthe
health infrastructure .The effects ofsome oftheprojects .areessentially
local (Dahomey ,Madagascar 8,while others arecountry-wide projects
integrated harmoniously into thenational health development plans (Upper
Volta ,Niger )♦From thetechnical ,functional andoperational points of
view ,thedesign oftheprojects canbeconsidered ascorresponding inmost
cases tothe country 'sstructural requirements .The effects oftheprojects
therefore seem tobelargely positive ,but ,generally speaking ,theuse made
ofthe .major hospitals isgreater than that made ofthe/health ",units at
theintermediate levels and considerably greater than theuse made ofthose
attholower levels ofthe "publio health pyramid ".
The effectiveness ofcertain health units financed bytheSDF hasbeen hamper­
edbyinsufficient operating resources .Staff shortage problems have ,however ,
generally speaking eased over theyears .Asregards themaintenance of
equipment ,thespecialized staff training programmes instigated andfinanced
bythe'Community constitute apractical andeffective step towards solving the
problems encountered .Incontrast ,theinsufficiency ofthecountry 'sown
financial resources toensure theproper Operation ofthehealth units
remains thecrucial problem .Lastly ,-theanalyses show that theutility
andutilization ofhealth projects canbejeopardized unless certr.in conditions
are fulfilled inrespect oforganization ofthehealth system and inthe
fields complementary toit;regulations onclearing ofpatients andadmission
tohospitals ,education ,water supply ,etc,.

-5- VIIIA67 /75-B
UTILIZATION OFPROJECTS
I.Activities ■
Anexamination oftheutilization ofEDF-financed projects suggests a
number ofgeneral points concerning inparticular hospital occupancy and
the activities ofthe health units .
1)Hospital occupancy .
Generally speaking ,theoccupancy rate ofthemajor ,general hospitals hav
ingallresources fordiagnosis andmedical treatment ishigher than
that inthemedium sized hospitals andhealth centres .Among the
i
general hospitals ,wefind thefollowing occupancy rates :
approx .90%atMajunga (Madagascar ),Mogadishu (,Somalia ),
Niamey (Niger )
approx .100$ atNouakchott (Mauritania ),Zinder (Niger
Incontrast ,the "secondary "hospitals .andhealth centres established
attheintermediate andlower levels ofthepublic health pyramid generally
achieve anaverage occupancy rate ofbetween b0%and70$ ,butwith
marked differences from one establishment toanother within asingle
Country .InUpper Volta ,forexample ,thehealth centres atZiniare t
andKongoussi areclearly underutilized (JQ% )while thehealth centre
atYako is*used tofull capacity (100# ).
Thelower occupancy rate attheintermediate level isgenerally •.
accompanied byashort average period ,ofhospitalization ,(approximately
10days ),which innocase exceeds 15 ,days .Inthegeneral hospitals ,
ontheother hand ,thepatientsare hospitalized onayerage forbetween 20
1)Bycomparison :80%atOuagadougou and100# atBobo Dioulasso
(Upper Volta )»hospitals nonfinanced bytheEDF .

-6- viiy^67/75-E
and 25days ,Naturally ,anexcessive inflow ofpatients mayoblige a
hospital tomake asharp cut'intheaverage period ofhospitalization ,
ashasbeen thecase inNouakchott (Mauritania )nndatOuagadougou
(Upper Volta ),where itdoes notexceed 10to12days .
2)Other activities ;
Itisnotpossible from thefigures available topinpoint any general
trends forother activities (consultations ,operations ,childbirths ,
etc.).Thenumber ofconsultations carried outseems todepend essentially
onthereputation andmedical attraction oftheestablishment ,which are
based onthequalifications andreputation ofthemedical andnoir-phy3ician
orancillary medical staff *Theexamples ofUpper Volta andITigor show that in
general theactivities ofthehealth units attheintermediate level
are greater iftheunits aremanaged byadoctor and notbyamale nurse .
1
3>;Summary ,
Ananalysis ofthe various findings relating totheactivities ofmedical
establishments underlines basic and obvious points :theuse made of
ahealth unit depends
-onthe condition andmaintenance ofthebuilding ,the fixed
installations and themedical equipment , -
-thenumber ,qualifications ,initiative anddynamism ofthe
medical ,non-physician orancillary medical and "auxiliary staff ,
-the financial resources that the unit can call onfor its
operation ,
the additional material resources that the unit can obtain :
medicaments ,small-scale medical equipment ,etc.,
/

-?- VIIIA67 /75-E
-thefunction assigned tothemadioali unit wrthin thopublic ,health
pyramid ,
-the fulfilment ofcertain additional conditions necessary for
smooth operation (regulations onclearing ofpatients andadmission
tohospital ,road conditions ,availability oftransport ,etc .),
~thelocation oftheunit inrelation topopulation density and
distribution and toother establishments inthehealth pyramid
ortheprivate sector ,
-itsmedical potential inrelation tothe density and distribution
ofthepopulation served (here ,theregional distribution hasa
greater influence than thepopulation total ),
-thecontinuity andregularity ofthehealth services supplied
(therotation ofexpatriate staff forexample ,afrequent
practice ,does not establish astrong basis ofconfidence
between doctors andpatients )., ,
•simultaneous andcomplementary activities inthe fields of
preventive medicine ,health education ,hygiene ,health protection
formothers andchildren^t&A theintensity andcontinuity ofthese
activities ,
-theinterest orlack ofinterest onthepart ofthelocal
authorities ,
-intheshort-term ,thetimetable determined bytheeconomic
activities ofthepopulation (harvests ,possibilities oftemporary
paid work inthefields ,market days ,vaccination ofcattle ,etc .).
/.

-8- VIIIA67 /75-E
II.K&intemnce ofbuildings and equipment
Themaintenance ofbuildings andequipment is'oneoftheweakest points
intheutilization ofall projects carried out .*
1)Buildings
Ingeneral itisfound that thebuildings aremaintained inafairly -
regular andsatisfactory way inthemajor hospitals andinthehealth
units run with external aid .Incontrast ,maintenance isoften
insufficient oreven non-existent inhealth units atthe intermediate
and lower levels .
Generally speaking themaintenance ofinternals (plastering ,painting ,
window anddoor frames ,etc.).ismore neglected than themaintenance
ofthebody ofthebuildings .
Although theGovernments have become aware oftheneed tomaintain
buildings ,the funds available are often insufficient orare used
tofinance other construction work considered more important ormore
urgent .Inthemajority oftheAASM ,itistheMinistry ofPublic
Works which decides theorder ofpriority formaintenance work in
allsectors ,but without always having objective criteria . ,
2)Equipment
Generally speaking the degree towhich equipment ismaintained -isin-
inverse relation toitscomplexity (fextremc casern arcrefrigerating ,electrical
andheating plant 3,lifts ,sophisticated medical equipment ,etc.)# The
often rapid deterioration ofeq'uipmeiit isdueinparticular to
'■-thoinsufficient quantity andquality ofuaintenejico staff ,
-theindifference oftheusers (medical andancillary medical
staff ,administrative staff ),whoareoften ill-prepared for
-rV •theuse ofEuropean-type equipment (lack ofinformation and
understanding ,lack ofmotivation andinitiative ),

û VIII/*f67/?5-E
-theslenderness ofmaintenance ^budgets , ...:*>•- .,. -
.-theabsence oftechnical andmanagement ^structures "! :i-
atnational level ,itiparticular theabsence ofgeneral naintcnance
schedules and ofwork and control cards inhospital units,.' .
This toois"a more serious problem forthemedical units inrural areas ,
since thevarious measures adopted atnational level and foreign aid
projects -(EDF ,SWHO ,bilateral 'aid ,etc.)have helped bring about an
appreciable -improvement inthemaintenance situation inthemajor hospitals
* *
Toavoid prolonged breakdowns ,more account should betaken ofafter -
sales Service inthechoice ofhospital equipment ,The suppliers of
equipment ,could beobliged ,nnder -mcrets$rict conditions than inthepast ,
toguarantee theafter-sales service oftheir equipment .Inparticular /
they c<puld beobliged inthegeneral conditions ofsupply contracts to,
-give users apractical demonstration oftheoperation of :./ ..
items ofequipment , :
-tospecify thesteps tobetaken tomake use oftheafter-sales
service , •,.
-supply avery simple guide ormaintenance cards which canbe
j .
easily assimilated byboth theuser andmaintenance staff ,
-supply acatalogue fortheacquisition ofany spare parts required .
3)Programmes for "thetraining ofmaintenance staff
The Commission' isaware ofthe fact that the solution ofmaintenance
problems .is *an .essential condition fortheproper -functioning andfull
utilization' ofahospital , •– drawing on .the
conclusions ofanexamination .oftheusebeing made "ofcertain hospital
projects -hassuggested andfinanced anumber ofprogrammes fbi **$hotraining of
1)maintenance staff .These programmes provide fort
•/•
l)Cameroon :training ofgeneral-purpose maintenance workers andrepair
technicians formobile support ,supervision andmaintenance
teams (seeAnnex 1/21and1971 report ontheutilization
ofaid )
Mauritania :organization ofamaintenance service andtraining of
user ,maintenance andmanagement staff (seeAnnex 1/9);
Chad : inthecourse ofimplementation
Somalia :,.. .be-Lfig studied

-10- VIHA67 /75-E
-theadvanced training ofthe workers inservice on
themedicai units tocarry outcurrent maintenance work ,
-the training ofspecialists todetect faults and carry outmore
complex repair jobs ,
-the creation ,within theMinistry ofHealth ,ofappropriate
structures for theorganization ofmaintenance work ,
-thecreation ofmobile teams atnational level ,
-theeducation ofthemedical andancillary medical staff to
make rational useofequipment , . ''
»making theadministrative staff aware ofmaintenance and
organizational problems and therunning ofasmall stock of
spare parts .

-IX- VIIIA67 /75-B
Ill-Staff ofthe health units
The figures available oflthe ,number ofstaff allocated tothevarious
health units show uponly afewvery general trends ,theallocation of
medical andancillary medical staff atnational level iscarried outby
theMinistry ofHealth andbytherelevant subordinate administrative
department .Then ,within each administrative subdivision ,theallocation
of'fetaff tothevarious services (hospitals ,,health centres ,mobile teams ,
preventive medicine services ,.,etc .)isthe .responsibility ofthesenior
doctor incharge .Consequently ,thenumber ofstaff allocated tothe
. <. ... •
various units ateach ofthevarious levels can bevery unequal .
1)Staff numbers inthehealth units
From an .examination oftheway inwhich thevarious health units are
being used ,itisfound ,that theratio oftotal staff anddoctors to
capacity isvery favourable for thegeneral hospitals atMogadishu
(^20,including 31doctors ,for600beds ),andatNouakchott (200 ,
including 10doctors ,for230beds ).Theratio ismuch lower forall
theother units investigated jh'owever ,thedifferences noted between
oneunit andanother donotreveal ,any perceptible correlation vj.th
•thelevel .of'activities ofeach unit *
Generally speaking ,nearly all thehealth units have a ;number of
staff which corresponds toa defacto equilibrium resulting
from thelocal conditions ofutilization and thepossibilities ofthe
country .This isnottosay ,however ,that this ^number is"normal "
or"sufficient ",foronwhat basis should thenumber ofstaff required
bedetermined ?Should itbeonthebasis ofthe .technical requirements
oftheexisting installations andequipment ?Should itbeaccor­
ding toapre-determined ratio ofqualified staff tothepopulation
served ,that isaccording tothecriterion oftheoretical •

12- VIIIA67 /75-E
health requirements ?There isarisk that inthe .evaluation ofaparticular
unit itwill beheld that the staff allocated toitisinsufficient by -
European standards orbyother theoretical standards pre-- i
determined or on the basis of the subjective
on-the-spot assessment ofthose incharge even though theactual number
ofstaff maybeobjectively suited *to the specific -
conditions ofthecountry .Thequestion therefore arises ofwhether the
number ofstaff isinsufficient inthemajority ofunits reflects agene­
ralgap between theinitial idea andthecountry*s possibilities# '-Oris
thenumber ofstaff toogreat b<ycomparison inthe !major hospitals 1
mentioned above ?
Somalia ,forexample ,hasprovided itsMogadishu hospital with astaff
iigger than theAfrican norm ,and this seems tobethe
result ofapolitical choice rather than ofnecessity .However ,this
has directly created animbalance atnational level infavour ofthe
general hospital and tothedetriment ofall the other units .There
again ,itmust beadded that thenumber ofstaff means little initself
when wedonotknow thequalifications ofthis staff .Nojudgment can
bemade onthis latter point until more detailed investigations are
undertaken .
2)External technicn.1 assistance
Themajority ofthehospitals financed bytheEDFhave ,expatriate doctors
theefforts toreplace these doctors are not very faradvanced except in
theMogadishu general hospital (25Somalis outof^1doctors )andin
thehospitals inMadagascar (taking thecountry asawhole ,6l7out
ofthe667doctor 'sareMalagasy )•
Inthe other countries ,itwould beabsolutely impossible tomaintain
the current level ofactivities without thegreat numbers ofdoctors
provided bytechnical assistance schemes .French doctors ,forexample ,
help intherunning ofthehospitals atNouakchott (Mauritania ),
Zinder (Niger )andVictoria andGaroua (Cameroon );there are
German doctors working inthehospitals atGaoua .(Upper Volta ),
Tahoua (Niger ),

-13- VIII/467/75-E
* ' "
andBelgian doctors inthehospital atDosso (Niger ).
Innearly all thpcountries theprovision ofnational ancillary
medical staffismuch further advanced ;nevertheless ,anumber of
European nurses andhealth assistants areallocated particularly to
units runbyforeign technical assistance .
"Preventive medicine staff
Generally speaking the .units responsible forpreventive medicine ,
inparticular themobile teams (e.g. inUpper Volta andNiger )do
nothave all thestaff that they need .InNiger ,forexample ,where
the'EDF has financed .thecreation ofsixcentres asfixed bases for
themobile medical teams'^,theshortage ofstaff ,inthemobile teams
forthedetection andprevention ofdisease isproving areal obstacle
totheimplementation ofthenecessary action that isplanned .These
mobile teams arenot .able tocarry outaregular programme forthe
detection ofcertain diseases throughout thepopulation covered ,
which means that their often work asemergency' treatment rather
2)than détection units .
1)Hygiene andmobile medicine teams t.Equipes d'hygiène et .dé
■■'mêdicine njobile EDHMM )• '•
2)IntheGaoua health sector inUpper ..Volta ,theonedetection
,team inoperation ,consisting ofseven members ,can cover the
whole population of350.000 only every kor5years .

-IV-VIIIA67 /75-E
IV.Budgets ofthe health units
1)Preliminary remarks
Inorder toobtain anidea ofthe general level ofoperation ,hospital
budgets are considered below frora theangle ofexpenditure effected ,
noaccount being taken oftheorigin ofthefinancial resources .This
.origin will beanalysed separately .Staff costs will be
considered only inexceptional cases #given that thelevel ofsuch costs
depends onthebreakdown between national staff and foreign staff
(financed bythevarious technical assistance schemes )*
The .operating budgets (staff excluded )give an
indication oftherequirements ofand theresources available tothe
establishment .Anumber ofreservations regarding this method must be
made ,however :
-medicaments account fordifferent amounts depending onwhether
they are
.bought directly from European .suppliers (e.g. general hospital
inMogadishu )'}.),
.supplied through theintermediary ofanimport organization
(e.g. theOffice National desProduits Pharmaceutiques et
Chimiques inNiger ),butwithout being exempted from customs
duties ,
.partly supplied inkind bytheMinistry orbyother aid
organizations (Upper Volta );
-thefeeding ofpatients accounts fordifferent amounts according
towhether itiscovered byinternational food aid (Upper Volta ,
Niger );
,--themaintenance ofbuildings may beeither charged against the
hospital 'sbudget ortaken care ofbytheMinistry ofPublic
Works from itsownbudget ;
1)Through theMinistry ofHealth *since they arenotsubject tothe
import procedures oftheASPIMA (State Agency fortheproduction
andimportation ofmedicaments ),their cost price isapproximately
50Jo oftheSomali market price .

• v' –15-' VIIIA67 /75-E
' ■•"" l .î-f .
-innocase was itpossible toobtain abreakdown of -the
(budget 0. between thevarious activi-ties ofthehospitals ;
consequently ,the figures calculated for theoperating budgets
: ■- foreach bed and 'each dr.y'shospitalization .constitute only a
• very rough approximation .and canbeofcomparative .(value only *
2)Operating budgets
From anexamination o'f :anumber ofprojects fihanced bytheEDPand
from various other sources ofinformation ,itcanbeseen that asa
general rule theoperating budgets (staff excluded )expressed in
.. . , , 1)terms ofoperating costs perbed per annum
-arerelatively high forthegeneral hospitals ,inNouakchott
.» (230beds ),Niamey (700beds )„andMogadishu (600beds )i
.between CFAF l80.0C0 andCFAF 320,000 ;
-areaverage forthegeneral hospitals inZinder (Niger ,4-50beds )
Bobo-Dioulasso andOuagadougou (Upper Volta ,700and730beds
respectively )andMajunga (Madagascar ,550beds ):between
CFAF 100.000 andCFAF 160.000 J :> , ,
«rarerelatively low inCameroon forallregional ,departmental and
< arrondissement hospitals :(capacity ofbetween 30'and300beds ):
between CFAF 30»000 and CFAF 90.000 ;
-arealso low forthedepartmehtal hospital centres atTahoua and
Maradi inNiger (136and166beds respectively)and inthehospital
5atManakara (Madagascar ,150beds ):between CFAF 80.000 and
* : •CFAF 100.000 . '
The first conclusion reached isthat thegeneral hospitals seem tobe
better provided with operating funds than theintermediate level
2)hospitals ;this conclusion remains valid even ifonetakes into account
the greater needs ofthemajor hospitals asaresult oftheir more
extensive equipment ,their greater immber ofspecialized services and
*• ' * *
their more ambitious operating "conditions . .
•' «j. • •• ', , r • \
There areanumber ofexceptions ,however :"inUpper Volta ,thetwo
secondary hospitals inQaoua (120beds )andFada N'Gourraa
' !
1)Reference years :Nouakchott :1972 ,Niamey andZinder :1975t j
Mogadishu :1973 »BoboDioulasso andOuagadougou :1973 •Majunga :197*N j
Cameroon 1970/71»Tahoua aàdMaradi :197^»Manakara :197*+« ;
2)theinsufficiency oftheoperating appropriations ,especially forthe j
bush medical units ,wasmentioned inthe19^9 report ontheutilization
<5#aid (P*^9 )»particularly inrespect oftheCentral African Republic

-16- VIII/467/75-E
(130"beds)haveanoperatingbudgetperbedofbetweenCFAF200.000l)andCFAF300»000'.Thereasonforthisisthatbothofthesehospitals -
constitutethefirststageinalargerproject#Theoperatingcostsof
thepresenthospitalsarethereforemadetolookexcessivelyhighbecause
oftherelativelylargeamountofequipment,whichisgearedtothefinal
plannedcapacity.Thesamereasonscouldapplytotheveiyhigh
operatingcostsperbed(CFAF330.000)oftheNouakchotthospital.
Anotherinterpretation wouldbethattheoperatingcostsofthetwo
secondaryhospitalsinUpperVoltaarecoveredbyforeignaidattoo
highalevelcomparedwiththeoperatingresourcesthatwouldnormally
beavailable'tohealthunitsinthatcountry.
Theoperatingcostsperday'shospitalization inthegeneralhospitals
generallycorrespondtotheoperatingcostsperbed.Theyareinfluenced,
however,bytheaverageperiodofhospitalization ,andarebetweenCPAS'
950andCFAF550forthehospitalsinNouakchott,NiameyandIlogadishu
andbetweenCFAF450andCFAF350forthehospitalsinZinder,Ouagadougou
andBoboDioulasso.
Asecondgeneralviewtobedrawnisthatthereisnoapparentcorrelation
-between,ontheonehand,theoperatingbudgetsofthehospitalsand,onthe/
otherhand,thepercapitatotalhealthexpenditure andpercapitahealth
operatingexpenditureofthecountriesconcerned.InCameroon,theper
capitahealthexpenditure (CFAF650)andthepercapitalhealthoperating
expenditure (CFAF172)bynomeanssignifyan'adequate'le\nolofoperation
inthehospitals,whereasinUpperVoltadespitethelowlevelofbudget
resources(CFAFI65andCFAF22percapitarespectively),themajor
hospitalsoperateatafairlyhigh'level.Thisphenomenonisexplained
bythefactthatthehospitals'budgetsreflecttherequirements ofthese
healthunitsratherthanthefinancialresourcesofthecountry,forthe
budgetsoftheunitsarenotinallcasesprovidedsolelybythehealth
budget..-Becauseofthis,itisnecessarytoanalysetheoriginofthe
funds. - • •• ■,-■
■./.
l)Theseoperatingcostsperbedareinfacthigherthanthoseofthe
country'stwogeneralhospitals.

_17_ VIII/467/75-E
I
3)Sources ofbudget funds
The"budgets "ofthehospitals come from afairly wide range ofsources .
Ingeneral ,they include thefollowing :
-theMinistry ofHealth with more orless regular amounts for
.thenational medical ,ancillary medical andadministrative
staff and themajority ofthe -auxiliary staff andlabourers ,
•"'the operation of .theunits atthehigher and intermediate level
-theregional andlocal authorities with amounts which vary
"according tothe taxrevenue actually collected ,these amounts
being used for
.aproportion oftheauxiliary andlabouring staff ,
.themedicaments ,small-scale equipment ,fuel ,etc .used bythe
intermediate andlower level units and .in'particular bythorural
dispensaries »
-bilateral financial aid tomeet operating ,maintenance andrepair
;■costs ;
->fairly irregular sources ofmultilateral financial aid ,for
- •example theCheysson Fund forthepurchase ofmedicaments and
medical equipment ,V/HOforcertain campaigns against endemic
diseases ,etc .;
-irregular aidfrom private organizations (e.g. theLyons Club )
. . 'andother sources (e.g,CARITAS ,MIS12RS0R ,Deutsches Aussätzigen
Hilfswerk ,etc »)•
The additional aid inkind from all sources must 'also betaken into
account .
This includes
-atnational level ,inUpper Volta forexample ,the "Contribution
Patriotique 11and theNational Lottery for thepurchase of
ambulances ,
-atinternational level ,theaid inthe form ofmedicaments and
,equipment supplied byprivate ,philanthropic ,religious andother
cv.prganii&tions ,and food aidifrom varioas sources .

«18- VIIIA67 /75-E
Incertain countries ,only avery small part oftheoperating costs of
thehealth units isfinanced from the country 'sownbudget resources
(health budget andlocal authorities )«Itisonly with •'
financial and other aid that theexisting health units canbeoperated
inasatisfactory way .Forall these reasons ,theactual budgets ofthe
various units arevery variable ,irregular andoften difficult to
determine . . . .
k)Defacto balance oftheoperating budgets
Tosumup,avery fragile balance hasbeen achieved intheope-ip /tingbudgets
ofthemedical units inthemajority ofthe ,countries -thanks tovarious .sources
ofexternal aid* Itappears that there isa-.tendency for ■
theGovernments toallocate their available financial resources ,in
decreasing order ofpriority ,tothemajor hospitals ,then tothe
intermediate level units andfinally tothebasic establishments ^
Inversely ,thelocal authorities arecalled ontoensure theoperation
firstly ofthe intermediate level units and then ofthebasic units ,
inparticular thedisponsaries . .......
Consequently ,external aid fills inthegaps .atnational level andmust
inmost cases bedirected totherural areas .Conversely ,aidforan
upper level unit may free budget resources for th?lower levels .
Forexample :French operating aidhasbeen supplied regularly and
continuously over anumber ofyears tothehealth sector inUpper Volta .
Because onehalf ofthis aidwasearmarked forthetwogeneral hospitals
inOuagadougou andBobo Dioulasso ,budget resources could betransferred
bytheMinistry ofHealth toother units and tosocial medicine.'
There is .therefore asort ofsystem ofcommunicating vessels ,inwhich the
distribution ofthebudget resources isdetermined by,theorder o.f
"preferences "laid down (e.g. infavour ofthemajor hospitals )and
theconditions governing theallocation ofexternal aid .
./

-19- VIIIA67 /75-E
5)Levelof opération
The existence ofadefr.cto balance intheoperating budgets inno
waymeans that thebudgets are suited totherequirements asoriginally
conceived . Inmany units current operations are
farfrom reaching thelevel originally aimed at.Itispossible to
evaluate " theexact recurring expenses only bytaking
account ofall theinfluencing factors ,inparticular the
characteristics ofthe technical andarchitectural design ,the
technical installations and .medical "equipment ^the .operating conditions
oftheelectricity andwater supplies and thehousekeeping installations
'(kitchen ,laundry ),etc.."
6)Structure ofthebudgets
The information obtained issufficient only forvery general conclusions
onthedistribution ofthebudgets .Onaverage ,the operating budgets
""ofthe ma.jor hospitals breakdown asfollows :
50%isused formedicaments andsmall-scale medical equipment (with
variations ofapproximately 20%depending onthepurchasing
possibilities ) '
*25%isused forfeeding patients (with variations ofapproximately
l*G%depending ontheusemade offood aid ).
"Thecost of "medicaments (andsmall-scale medical equipment)per day's
'hospitalization isbetween CFAF "200andCFAF 250 forthegeneral
hospitals ^inBoboDioulasso ,Ouadougou andMogadishu andover
CFAF 250 forthegeneral hospitals inNiamey andZinder (Niamey :
' -v'*'CFAF 565 ).
Ithasnotbeen possible tocalculate acorresponding figure forthe
intermediate level hospitals . \
,-.,ΐ ■ ■·. ····· " ■""· ■■-·ί ■■ ■"*'·· ■ '·'·./·
1)1973 ,figures „ . ... . ,, . >_,
2)1975 figurés''

-20 VIIIA67 /75-E
7)Revenue
Nearly all thecountries have introduced asystem ofcharges in .the
major hospitals (e.g.Upper Volta ,Niger )"^oreveninthemajority
oftheir hospital establishments (e.g. Madagascar ).InSomalia ,all
medical services have been provided free ofcharge since 1972#
Ingeneral ,thecharges apply tothenumber ofhospitalization days
(andnottooperations ),There arevarious categories ,and the
charges range uptoamaximum ofCFAF 3»000 perday inMadagascar and
CFAF 2.^00 perdayinUpper Volta .Normally ,there arespecial terms
forcivil servants ,whopayareduced charge (e.g. inNiger ),
generally about 20^ofthenormal rate ,which isdeducted from their
salary ,while theremaining S0% orsoispaid bytheState .
There areother rates foroutpatients (CFAF 500inthemajor
hospitals inUpper Volta ),forchildbirth (flat-rate charge of
CFAF 300inUpper Volta )oreven for thehealth education schemes
2)- '-1untertaken onthe initiative ofcertain doctors ...
Therevenue thus obtained issometimes quite considerable ;atthe
Nouakchott hospital forexample ,,itcorresponded in1970 .tothe
.hospital 'soperating budget .Attheregional hospital atMajunga
(Madagascar ),such revenue amounted to60?c j©f .theoperating budget
(1975 )*while itdidnotexceed 10%inthehospitals atManakara
andFort Dauphin (Madagascar ).
1)Forexample :inUpper Volta ,thetwogeneral hospitals at ,Ouagadougou
andBobo Dioulasso and thesecondary hospital atOuahigouya .In
Niger ,the two general hospitals atNiamey andZinder .
2)Forexample ,a"charge "ofCFAF 25permonth isrequired for
participation inthematernity and child health courses atthe
■health centre inYako ,Upper Volta .

-21F VÏII/H67/75-.E
InNiger ,thetotal revenue ofthetwogeneral hospitals represents
Only 5$ofthehealth operating budget .InUpper Volta^'th'e correspond
Ingfigure fortherevenue "ofthetwogeneral hospitals is20?o ,while
therevenue ofthethird paying hospital (Ouahigouya)is practically
zero .
Theproblem ofthecharges system isthat thehospitals have no
financial autonomy ,andall therevenue must bepaid into the
Treasury .Inspite oftherelatively favourable impression given by
theabove figures ;there isarisk that because ofthis rule the
hospitals will have homotivation tocollect thecharge 'sfrom the
'patients.' 1$would beinteresting toseewhether itwould notbe
possible toincrease this revenue bygiving thehospitals some
financial autonomy .
Moreover ,there isthequestion ofprinciple ofwhether there isa
danger ,with thecharges system ,ofputting thehealth services
effectively out Jofthereach ofthemajority ofthepopulation .
Experience hasshown ,however ,thai inspite oftherelatively high
■rates .charged ,inMadagascar ,'forexample ,approximately 20$ofthe
patients .usethesystem .Theexample ofthehospital atFort Dauphin
(Madagascar )hasinfact shown that thepaying clientele prefers
ithe ;private hospital atManambara (23km away ),despite thehigher
;level 'ofcharges^# ■ " • v •- *

-22 VIIIA67 /75-E
Médicaments . " •
Adiscussion ofthemany problems connected with thesupply and
distribution ofmedicaments would exceed the framework ofthis report .
Asaresult ,only a.fewinteresting points will bementioned .
Theprescription andsupply ofmedicaments isgenerally free ofcharge
forpatients treated in .themedical units .Out-patients ,onthe .other
hand ,buythem attheir ownexpense from pharmacies (forexample ,
inUpper VoltaandSomalia ).These principles .seem ,however ,tobe
applied inavery flexible manner .Aformula that isfull ofpromise
has be.en introduced in lligcr : itwasfound that 60$ofall
therecorded cases ofinfection can betreated with five medicaments ,
and asystem ofvillage pharmacies and ofvillage first-aid public
health workers hasbeen setup.This scheme ispart ofamajor
programme ofsocial andpreventive medicine ,andhas thefollowing
advantages :itcanberuneconomically via thesale ofthese five
medicaments ataunit price ofCFAF 5and itisplaying auseful part
inthehealth education ofthepopulation .
Asfarasthesupply ofmedicaments isconcerned ,private aid isoften
ineffective .Fairly often one finds inthehealth units unused and
unusable quantities ofmedicaments sent byprivate andphilanthropic
groups ,etc..For this aid tobeofmaximum use ,itisimportant :
-that itbeadapted totheparticular requirements ofAfrica ,
-that thenumber oftypes ofmedicaments bereduced toa
practical minimum suited tothepharmaceutical experience
ofthenational ancillai-y medical staf&

-23-
*Iv-*VVIII/1f67/75-E
Better results could beobtained ifthis private foreign saidwere ,,sent
direotly tothedoctors ^o)i-the-.spot sothat they could detail their
particular requirements ,. ■; ~ !
Similcfrly ,itisvery much intheinterest oftheGovernments tomske
a.strict ,selection ofthevarious types ofmedicament ,since :this
alone pan ensure ,arational and effective useboth ofimported
medicaments and ofthe .budget resources that are .spent .Itwo"uld be
1
interesting tostudy these problems indepth ,especially theoperating
conditions ofthe^eupply pharmacies andquestions relating to -the
utility cyadprofitability ofthepharmaceuticals produced in>number
ofAfrican countries *
Itwould also beofinterest tostudy thepossibilities ofusing
traditional medication based onlocal iow-cost rawmaterials .This
woiild make itpossible toreduce theexpenditure onimported
medicaments butwould presuppose aspecial effort tostudy such local
medicaments scientifically andinstruct medical staff intheir use .

-2b~ VIIIA67 /75-E
OVERALL COHEMTCE OFTHEPROJECTS ATITATIPITALLEVEL ...1
After taking alook athow theprojects financed bytheEDFareoperating ,
itisessential tosituate them inthe context of ,the overall national
effort inthehealth field and tomeasure their efficiency inthe
light ofthestrategies adopted bytherelevant authorities .Consequently ,
anexamination will bemade of:theplace and function ofthehealth units
that have been setup,their contribution tothedevelopment of
infrastructure and their consistency with thehealth development plans .
Naturally ,this evaluation cannot bemade without taking into consideration
theoperating resources (staff ,funds )that areavailable ,since these
effectively determine thedegree of efficiency and ,ultimately ,the
operating level ofanyhealth unit .
1.Place oftheprojects inthedevelopment of'thehealth infrastructure
1)Isolated projects
a)Health units inDahomey andMadagascar
The projects carried out from theresources ofthe first EDF
inDahomey andMadagascar involved -theimprovement ,"modernization
•and extension ofexisting "hospitals or .health units# Their common
andmain objective' was toimprove theequipment andpremises
ofthese units soasto:
*•'ensure improved quantitative andqualitative output
from thestaff ,
-cope better with regional andlocal health needs .
These isolated projects are the .result ,ofchoices made on .the
, _basis ofpresumed needs andpriorities andarenotintegrated
into adevelopment plan orhealth policy ..Itwasonly inthe
yeajrs following independence that themajority ofthe,AASM
formulated their health requirements more systematically .

........ -.25- VIIIA67 /75-E
l
Thedefinition oftheobjectives andresources ofanational health
policy hasmade it .'possible t© .tailor subsequent .projects to , '
development plans . .x' . •:--
For this reason ,theutility and efficiency ofisolated projects
carried out during the early years oftheEDF'sexistence canbe
' y .* ' 'judged only onthebasis of'local criteria .Even though' the'design
might appear suited tothelocal situation ,itisnotnecessarily so
atnational level ,forthere isadanger that anyisolated project
"produced' inthis adhocwaywill beput tothebest possible use
only iftheexisting health infrastructure into which itisfitted
constitutes acoherent ,functional system that canbeimproved ,
modernized ,ddded to,enlarged and given abetter internal balance .
Ofcourse any consideration oftheexisting infrastructure must not
ignore theprivate sector establishments .Clearly insufficient account
was taken ofthis aspect inthe case ofthereconstruction ofthe
hospital inFort Dauphin (Madagascar )-hence thefairly low
degree ofutility ofthisproject ^.
'J.«' '>* '' *' ''•. ' '
National hospitals in -Mauritania and Somalia
Theprojects for theconstruction ofnew general hospitals in
Mogadishu (Somalia -)andNouakchott -(Mauritapia )hadquite different
objectives :inSomalia ,theaim .was to ,replace theoldgeneral
hospital (DiMartino )}inMauritania anewgeneral hospital hadto
bebuilt inanew capital city .
Intheabsence ofanoverall health policy ,theobjectives ofthese
projects were dictated byanexisting special situation .InSomalia ,
thepriority ,and'infact sole ,objective oftheItalian Trusteeship
Administration "was toreplace theoldgeneral hospital# InMauritania ,
thealmost complete lack ofahealth infrastructure andtheexcessive
number ofcases where seriously illpatients were taken toSenegal
o*Mali made thecreation Ofageneral hospital amatter ofpriority#
Since they reflected .basic necessities atnational level ,,these two
'projects were not .isolated projects inthesense referred to
earlier ; ,*/•
1)SeeAnnex I/kand1971 report ontheutilization ofaid (pp )„

-26- VIII
infact ,although they were notintegrated inatruly structured aiid
•jr •
coordinated health system ,they merely anticipated theobjectives of
afuture health policy "^.
Inthetwocountries inquestion ,thase hospitals constitute real
national hospitals with ahigh degree ofspecialization and with all
thenecessary resources fordiagnosis andtreatment .TheMogadishu
hospital ,however ,does not really fulfil the role that should beplayed
byahospital atthe top ofthehealth pyramid since ittakes patients
from theinterior ofthe country only onanoccasional rather than
asystematic basis .Infact ,itserves thepopulation ofthecapital
"almost exclusively .InNouakchott this local function wasanintegral
part oftheoriginal plan ,but theoutpatient activities have
overwhelmed thehospital tosuch anextent that theproper functioning
ofthewhole unit hasbeen handicapped .
One may wonder whether theessentially "local "use ofanational
hospital does not constitute awaste ofitsprofessional capacity and
ofitsprecious and costly equipment .The existence ofan
2)institutional barrier (rules onadmission )could
-guarantee arational use ofhealth uiiits atalllevels ,
-make itpossible toreserve thenational hospital for those
patients whorequire specialized tests and treatment .
Inthelight oftheabove ,thequestion arises ofwhether thedecision
toconstruct anational hospital inthese two countries was justified .
InSomalia ,for thereasons given ,any alternative
solution vasexcluded from thestart ,andanyreflection onsuch
possibilities canonly bespeculative ,since itspurpose would be'to
reconstruct inretrospect thereasoning onthe choice which had tobe
made .Even taking these reservations into account ,itwould have been
possible ,instead ofbuilding anewhospital ,torestore ,modernize
andpossibly extend theoldgeneral hospital p.nspite ofits
state ofdisrepair . .
1)Such apolicy wasformulated inthecase ofMauritania ,when the
decisions were taken bytheCommunity ontheextension ofthegeneral
hospital and thecreation ofapolyclinic atNouakchott .
2)Forfurther details ,seesection 3»onpages 30/31*

•27- VIIIA67 /75-E
Thelatter choice would nothave .been atallunrealistic ,asis
proved bythefact that theoldhospital ,which wasdestined for
demolition ,isstill operating .
This shows that where there isanexisting infrastructure which
includes anational hospital thequestion ofreplacement must be
carefully studied .Everything must bedone toeither replace the
oldestablishment integrally andcompletely ortointroduce new
capacities step -by-step toreplace those oftheoldhospital at
thesame time .Anyparallel operation ofthetwo isharmful ,except ,
ifreally necessary ,where ,there isastrict andsystematical
allocation oftherespective functions andresponsibilities to
avoid competition . ,
InMauritania any theoretical alternative totheconstruction of
anational hospital would appear tohave been unrealistic .The
. .country hadanabsolute need forahospital unit provided With
specialized services fordiagnosis andtreatment inorder to
accomodate all theseriously illpatients who were previously taken
tohospitals inneighbouring countries .Theprudence shown in
designing theproject asthefirst part ofalarger hospital seems
tobeone ofthereasons for itsremarkable success .Bygiving the
hospital aninitially small capacity ,theGovernment was able to
,;ensure -itsproper functioning .Moreover ,thedesign proved ..
sufficiently flexible toenable extensions tobemade without ■
difficulties orinterruptions inthehospital 'soperation .
2)Comprehensive proiects (Upper Volta ,Niger )
;Theprojects financed from theresources ofthefirst andsecond EDFs
inUpper Volta -andNiger hadastheir common objectives *
•»theimprovement andmodernization oftheexisting
units belonging toageographically well established health
infrastructure (Niger ),

-28- VIIIA67 /75-E
-theremedying oftheshortcomings astoquality and
quantity intheexisting Jjospital infrastructure (Niger
andUpper Volta ), ,
-theimprovement orcreation ofworking conditions for
activities inthefield ofmobile medicine (Niger )orfor
campaigns against endemic diseases (Upper Volta ).
These projects involved thebuilding ,extension orimprovement ofa
number ofhealth units .They were designed toform the integral parts
ofahierarchical and coordinated system ,sothat all thehealth
units are the constituent parts ofapyramid-shaped whole .
Itisclear that theimplementation ofsuch large-scale projects is
dependent ontheexistence ofahealth development plan ,thepattern
ofwhich canbestatic (asinthecase ofUpper Volta )ordynamic
(asinNiger )." '
Although Upper Volta didnot have anywell defined health policy in
1961 ,theGovernment lost notime inconcentrating allitsefforts
onthedevelopment and improvement oftherural hospital infrastructure ,
particularly asamodern urban hospital infrastructure hadrecently
beenbuilt upwithFrench aid^v Allthese efforts werebased onthe
objectives formulated byageneral plan forthe future .V/ith theaid
ofthis plan ,itwaspossible totake balanced decisions for the
purposes ofEDF investment ont ~ ••
.the volume ofthe first instalment ofinvestments ,
.thecapacity andlocation oftheunits atthevarious
..leyels ofthehealth infrastructure .
However ,the "static nature ofthis general plan involved
therisk ofintroducing imbalances since thevarious stages ofits
implementation were not "defined .Logical andcoherent astheplan
might seem -,its 'implementation instages'
' ' '
1)Newbuilujng ofthegeneral hospital atOuagadougou ,modernization
andextension ofthegeneral hospital atBobo Dioulasso andofthe
secondary hospital atOuahigouya .

-29 VIIIA67 /75-E
orinsections depends ontheavailability atany given moment off
-qualified staff (doctors andancillary medical staff ),
-the country 'sown financial resources .
InUpper Volta ,"these two conditions were not completely fulfilled •
atthe time theprojects were completed ,inparticular asregards
thetwosecondary hospitals inGaoua and tfada N'Gourma .
InNiger ,onthe'other hand ,amore detailed programme forthe
reorganization ofthehealth infrastructure was drawn upbya
(Specialized committee .The "Prospects fortheten-year period 1965-197 ^
adopted bytheGovernment set out thepriorities ofahealth policy
andmade itpossible todirect investment inaccordance with certain
guiding principles ,which included :priority .forthose investments
which could increase theefficiency oftheservices while entailing
only aminimum ofadditional recurring expenditure ;priority for
therenovation ofoldbuildings inastate ofdisrepair ;the
principle ofbuilding upnewunits only when thequalified Etaff
wasavailable .Byitsdynamic nature ,thegeneral plan for the
future made itpossible
. -todetermine ina;very flexible way thestage -by-stage
adjustments -concerning quality andquantity -tothe
investment programme inthelight ofspecial andlocal
health requirements r ■•,
-toregulate inavery flexible way theplanned extension
<v 'i B-hdmodernization ,.
-toadapt inthebest possible way thesocio-economic and
technical characteristics oftheprojects tothecountry 's
.staffing andfinancial capacities . 1–
Theprojects have fitted harmoniously into theexisting infrastructure
and ithasbeen possible for the •cost ;oftheadditional -financing
<
andstaff tobeborne mainly from thecountry *sownresources .
-• •.*
The "Prospects for1965-197 **"hadanother essential advantage for
thodcvelopnent ofthehealth infrastructure iniliger «
•/•

-30- VIIIA67 /75-E
TheGovernment hadplanned tobase thepriorities orthehealth
policy onsocial medicine ,particularly mobile andpreventive
medicine »andhealth education .Consequently ,,thehealth structures
were designed topermit theadministrative and operational integration
ofcurative andpreventive medicine .Thehygiene andmobile medicine
teams ,whose newbuildings were financed bytheEDF andestablished
intheadministrative departments ,aroactive inthefields ofmedical
treatment (bysupervising theactivities ofthe .treatment units within
oach department ) ancj0fpreventive medicine anddisease
detection for therural population .Itappears that this integration
isfar harder toachieve inthose countries inwhich the health
infrastructure isbased essentially cnhospital medicine (e.g.
Upper \61ta ).
The project carried out inNiger raises yetanother interesting point .
In1962 ,theNiger Government submitted totheEDFaproject forthe
construction ofanewhospital atNiamey .However ,astudy ofall
theproblems involved showed that thesituation ofthecountry 's
health infrastructure was such that aseries ofextension and
modernization projects waspreferable .Itwas therefore decided to
opt foranalternative which proved tobeparticularly effective and
economical .InSomalia ^ontheother hand ,such anoption was not
possible ,asitwr,asaid hereabove . Itisprobable ,however ,,
that theconstruction ,improvement andmodernization ofanumber of
health units outside the capital would have made itpossible to
create abetter balance ofhospital capacity atnational level .
Ifitispossible tocompare these twosimilar initial situations ,
the choice made inNiger seems tohave been ofgreater benefit for
thehealth situation ofthecountry asawhole .
3)Complementary conditions
Acomparison between theprojects carried out inUpper Volta and
Niger reveals another important aspect .Inspite oftheprudent
nature ofthedecision onthenumber andcapacity oftheunits

-31- VIIIA67 /75-E
tobesetupinUpper Volta ,certain imbalances must benoted as
seen inrelation totheobjectives oftheplan for thefuture .The
lowoccupancy rate ofthetwosecondary hospitals (Gaoua andFada
N'Gourma )could lead totheconclusion that their capacity and
medical equipment are outofproportion totherequirements ofthe
population served^.Themainreason forthisunder-occupancy ,however ,
israther that thefunctional relationship envisaged between the
various levels ofthe "health pyramid "hasnotbeen achieved inpractice .
The irole' ofintcrnecliary clearing -centres,which ,wastobeplayed bythetwo
secondary hospitals ,iashort-circuited bythetwogeneral hospitals ,which
have theattraction ofbeing better equipped .
InNiger *byway ofcontrast ,theexisting pyramid-shaped health
infrastructure issupplemented bystrict rules laying down that in
principle nopatient ishospitalized andnoout-patient isaccepted
<f' " ' r
unless hecanprove that hehasbeen cleared byalower unit .
Accordingly *the twogeneral hospitals doinfact constitute the
topofthepyramid which isreserved fortheseriously illpatients
sent upfrom alower level .
Theconclusion tobedrawn from this isthat itisnotxsufficient
merely tocreate acoherent and .logical pyramid-shaped infrastructure
toensure that thevarious levels ,perform their allotted functions .
For thehierarchical ,coordinated infrastructure tobeable tofunction
under optimum conditions ,theclearing andadmission ofpatients must
begoverned byrules which ensure that theproper channels are
respected .Intheabsence ofsuch rules ,there isa.risk ,that the
use made ofthe health infrastructure will beunbalanced .
y( - ':: •/•
1}Ontheassumption ofthesame conditions asatpresent ,itwould
infact have been sufficient toconstruct atype B,i.e. more advanced ,
health centre (asatTenkodogo )with cperating possibilities andan
adequate hospital capacity inplace ofeach ofthe twosecondary
hospitals that were -built ..This isproved bythe fact that thetype B
health centre atYako (35beds )operates atahigher level of
activity than Gaoua andFada N'Gourma inspite ofitslocation
10§?kmfrom thegeneral hospital atOuagadougou ,

-32 VIIIA67 /75-E
Naturally ,theexistence ofsuch rules does not initself prevent
theclearing andadmission ofpatients being hampered inpractice
by
-insufficient transport (cars ,fuel ),
-roads permanently ortemporarily (during therainy season )
unusable ,
-absence orshortage ofqualified staff .
Asaresult ,itisdlearly necessary ,wh3n projects aredesigned ,
toexamine with agreat deal ofattention ways ofmeeting these
complementary conditions .
Summary
Tosumupthesuccess ofahealth investment project depends onits
harmonious and functional integration into acoherent and internally
balanced infrastructure .Atalllevels ,theexistence ofa(dynamic )
health development plan setting out thevarious stages ofimplementation
makes itpossible todetermine precisely thevolume ofinvestment to
bemade and toadapt such investment flexibly inthelight ofthe
country 'scapacity asRegards staff and funds .However *the
coherence and functional logic oftheinfrastructure cannot
gpar&ntee itsfull utilization atalllevels unless thenecessary
complementary conditions arealso fulfilled .

-33 VIII/467/75-E
Personnel atnational lcvel
(l)^Doctors ''
Exam nation ofuse is "being made ofprojects financed bythe3DFshow
that there isgenerally acertain defacto balance' between thenumber
ofdoctors assigned toamedical unit andthecapacity ofthat unit -
which does notmanthat oocarionnally atotal lack ofdoctors will
1
not befound insome units ".However ,atnational level .
•,-this situation maymfact only appear to"bea 1real ,balance ;
•<"• thelaok--ofa«-xt€Tt -a:?anunrbeir ofdoctors t"theoretically necessary ,
mayhinder -.iiapcrtc :at,possible activities ;•
••thedefacto bailee isachieved ,inmost ^countries ,only o.i.
thanks tothefairly massive amount ofaidfrom external
...technical asristance noi-fover itisavery delicate balance .
Tv:,enumber ofoaP,ii5fc.viat© doctors asapercentage ofthetotal
nuirber ofdot ;fccr.3 vaiies considerably from one -country ta
. . ,thenext ;83 "$>iaNiger andI'lauri tarda ,.10$inJfedagascar .
Moreover ,this apparent balance does notreflect thefact that atnational
level : ...
«*'the average ratio ofdoctors topopulation isgenerally still
•very lowandvaries ,forthecountries examined ,between one
doxeor .for11COOit.h&bitscrts (líadrgasóar ),áad50 -000inhabitants
(Nifrw)andevon 6.';<<yjOfuihaoxtan is(Uppér Volta ):
–there isahigh concentration ofdoctors mthebigtowns and
*•sgeneral hospitals tothodetriment oftherural areas }this is
shown bythe fciJowing figures forthenumber ofinhabitants per
doctor :
Somalia NifT_er Upper Volta
total forthecountry 19000 50000 66000
2capital city 3300 2800 8GOO
remainder ofcountry 43000119000^ 133000
•/•
{l)Pound forexample inCameroon andChad in1970
(Z)k'ievíj **for0uc%gn¿ongor .ardBobo Dioulaoso
(3)Cafcsi.de (oíNi&uey vná Z.>.2ler

-34- VIII/467/75-S
-thereisamajorimbalance iinnearly"allthe*iL
countries,namelythehighproportionofdoctorsassignedto
curativemedicinetothedetrimentofpreventivemedicine.
(2)Ancillarymedicalstaffandmanagementstaff
Generallyspeakingthestatementsmadeaboutdoctorsalsoapplyto
nursesandmidwives,',subjecttothefollowingreservations :,..
-thenumberofexpatriatenurseshasbeenreducedtoaminimum
followingtheacceleratedtrainingofnationalancillarymedical
staff}
-thevariationsfromonecountrytoanotherintheratioof
ancillarymedicalstafftopopulationarelesspronounoed
thanfordoctors,varyingbetweenonenursefor2800inhabitants
inDahomeyandonefor6100inhabitantsinSomalia?moreover,
theconcentration ofancillarymedicalstaffinthebigtowns
ismuchlessaccentuated .
Althoughthevariouscountriesmayatpresenthatoeenoughnurses,midwives,
etc.,thisiitnotthecasewithspecializedancillarymedicalstaff
(laboratorytechnicians *anaesthetists ,radiographers ,dentalmechanics,
etc.^.Thenumbersandqualityofmaintenanceandadministrativestaff
aregenerallyspeakingalsoinadequate.SinceeachStatecannotprovide
itselfwithaschoolforeachspeciality,itwillbenecessarytofind
inter-State ,solutions.
(3)Problemoftheshortageofmedicalstaff
Promtheabovefindingsitmaybeconcludedthatinmostofthecountries
medicaltechnicalassistanceisstillusedtoCompensatethelackofnational
staff,particularly doctors.Thisforeigntechnicalassistancestaffis
generallyfullyintegratedintothepublicservice,whichshouldnormally
implythatjobsaresharedoutfairlybetweenexpatriateandnational
doctors.Whatactuallyhappensisthat:

-35- VŒII/467/75-E
-mostnationaldoctorsareassignedtohospitalsinthebig
towns(ortotheMinisiryofHealth);
-mostexpatriatedoctorsareassignedtomedicalunitsin
ruralareas(inMauritania,forexample,outof9regional
centresonlyoneismm"byaMauritaniandootor).
Thisdisturbingsituationisattributable toanumberoffactors:
*•Firstofall,overhalfthemedicalstudentsatpresentin
Europeareunwillingtoreturntoenterthe-publicservice
oftheircountryoforiginbecause:
theyconsidertheremunerations offeredtotheminadequate;
theyareafraidofpoliticalandeconomicfluctuations in
theircountriesoforigin?
■theyareafraidofthephysicalworkingconditionsawaiting
them,whicharehardlycomparablewiththoseinEurope^*.
.*•Ifqualifieddootorsdoreturntheytendtoremaininthecapital
orinthebigtowns,disdainingtheruraland/orpreventive
medioinedepartments ;thetrainingreceivedinEuropehasshown
themth...gapexistingbetweenthesetwokinds-ofmedicinej
.'■■■„Moreover,sincemostofthedoctorsareaimingtobecome
specialists ,onlythebighospitalsareabletoofferthem
/•adequateworkopportunities .Onemayweliasktowhatextent
theseyoungEuropean-trained Africandoctorsinfluencethegeneral
tendencyoftheGovernmentstowishtocordtruotbigsophisticated
hospitals;
-Thus,duringtheearlyyearsofindependence animbalancearose
.amongthenationaldoctorsinfavourofspecialists andtothe
detrimentofthegeneralpractitioners .Yet,itisgeneralpracti­
tionerswhiohAfricaneedsmost.''
Privatepracticemightencouragethemtoreturn;however,inmostcountries
thepurchasingpowerisnothighenoughtoenablethenumberofprivate
practiceswhichareprofitable (byEuropeanstandards)tobeincreased*

VIII/467/75-E
(4)Afewconsiderations onpossiblemeasures
Onemaywellaskwhetherthebalance achievedbetween.tasksassumed
bytheStatesthemselvesandthosetakencareofbyforeign ,aidisnot
unhealthy;itmightbringStatestoneglectcertainessentialtaskswhich'
thenationaldoctorsfeellittleinclinationtoaccept.Whatconclusions
shouldbedrawnfromthissituation?Whatmeasuresaretobetakenor
havealreadybeentakentoremedytheseshortcoming ?.,.,
(a)Thetrainingofdoctors '■-
Itiswidelyaccepted nowthat .doctors
mustbetrainedinAfricanratherthanEuropean•-universities J*1
withcurriculatailoredtospecificAfricanhealthneedsandtothe
tasksofall-roundpractitioners ratherthanspecialists .Doctorsmust
alsobepsychologically preparedforthe workingandliving
conditionsawaitingthem.Themosthighlyqualifieddoctorsmaythenin
exceptionalcasesspecializeoncompletionoftheirstudies,orrather 1
afteranumberofyears'practipe,throughperiodsoftraininginEurope.
University traininginAfricahasalreadystarted:anumberofmedical
facultieshavebeensetup(forexample:IvoryCoast,Madagascar,Senegal,
.Zaire),.orarestartingup(Dahomey,Cameroon,Niger,'Somalia,Togo).
.Itwouldbeinterestingtocarryout.aspecialstudytofindouttowhat
extentthesemedicalfacultiesmeetthespecificAfricanneeds,what
willbecomeofthemwhentherequirednumberofdoctorsismetinafew
yearstime*andhowthehealthbudgetswillbeabletocopewiththe
additionalexpenditureresultingtherefrom.
It.mightbeagoodideafortheauthoritiesresponsibletoconsider
separatetrainingfortwotypesofAfricandoctorsfor
hospitalmedicine,
medicineoraedicalassistanceforruralareas.
1Forexample,thenewmedicalfacultyinMogadishuwillturnout
approximately 50doctorsperyearafterafouryearcourse.For
thesakeofcomparison,thecountryatpresenthasatotalof
153doctors,including58foreigners *,

0.r>-37-^ VIII/467/75-3
(b)Assignmentofdoctorgtortiralmgdiciiie .'*■^..\
*Itwould"beinterestingtbJstudypossiblewaysof'makingmedical
•graduatesdevoteaspecifionumber'6fyekrstorura'l"healthcare,
for"exampleby'makingauthorization topractisesubjecttothat
:■?conditioiiorbymeansofcivioservice.
Aformulaofthiskind"isajbliedinSomalia,where•doctorscannot
bepromoted,assignedtohospitalsinMogadishu,,orawardedgrants
tospecialize,etc.,untiltheyhaveworkedforseveralyearsinthe
bush»Mostcountries,however,hesitatetoapply.suchmeasuressince
theymightmakeyoungdoctorskeepawayfromtheircountriesevenmore,
(c)Improvementofworkingconditions ,,.
Itwouldprobablybe.agoodideatoexaminealltherealopportunities
forfurtherimprovingdoctors*workingconditions,especiallyinrural
areas,forexampleby:
•-greaterincentivestoworkinthebush,byawardingbonuses,
providingcars,improving ,accomodation ,etc.andbysettingupa
.minimumtJocialandoulturalinfrastructure (schoolstetc.),
'i^makingadequatequalifiedancillarymedicalstaffavailable;
-guaranteesregardingtheprovisionofregularand.adequate
medicalsupplies,medioalequipment,,etc.j.<
-guaranteesregardingcurrentmaintenanceofexisting ,;
installations ,etc.

-38- VIII/467/75-E
(d)Remplacement ofexpatriate doctors
Aslong asthere continues tobeashortage ofnational doctors
anymedical treatment which does notnecessarily require theservices
ofaqualified doctor should beprovided byassistant doctors or
ancillary medical -staff *Theexample ofNiger seems ofinterest
here :in'1974 theMinistry ofHealth grouped allthecountry 's
doctors together inthechief towns ofthedepartments ,where they
areresponsible ,throughout thedepartment ,
-forthecontrol andsupervision ofmedical care ,
-within themobile medical service ,forthedetection and
prevention ofdisease .
Thearea health centres andthedispensaries aretherefore run
exclusively bynurses .This rational utilization ofstaff goes
hand-in-hand with theincreasing availability ofancillary medical
.personnel . , '
Inthis field ,considerable progress hasbeen achieved invirtually
alltheAASM which have setuponeormore training schools forthis
category ofpersonnel .Koreover ,theCommunity ismaking aConsiderable
contribution tothis development ,theSDFhaving financed thebuilding
ofseveral nursing schools (e.g. Cameroon ,Dahomey ,Mauritania ,
Somalia ).- ''■ !
(5)Summary
Tosumup,during theearly years ofnational independence ,theusemade
ofthemedical units financed bytheEDFsuffered from theshortages of
staff andfunds .Thanks tothemany measures taken byGovernments andthe
various contributions ofaidfrom outside organizatioris fortraining ,the
problems ofmedical andancillary medical staff have been considerably
reduced }buttheproblems ofavailability ofoperating funds remain .
•/. ,
This scheme wasoutlined inthe1970 report (p.85)ontheutilization
ofaid .

-39- VIII/467/75-E
*' ■»"
III.Healthbudgetsatnationallevel
(l)Preliminaryremarks 'V-.:
..Inorderto.provideafaircomparisonofhealth'expenditures inthe
,countriesexamined,onlythe'ordinary -"health-"budgetshavebeenconsidered,
,withoutaccountbeingtakenofappropriations forcapitalprojectsor
.localauthoritybudgets.Theordinaryhealthbudgetsdonot,forexample,
.:.include:
-thecostsofhospitaltreatmentforpublicofficials(borne
bytherelevantministries), .
*-thecostsoftransporting andprovidinghospitaltreatment
for,thepoor(bornebylocalauthoritybudgets).
Inviewofthediscrepancies -whicharesometimesconsiderable-
'betweenforecastsandallocations made,accounthasbeentakeninsofar
aspossible •onlyofactualexpenditure.
(2)Characteristicsofthebudgetarysituation
Followingtheanalysis .oftheamountsspentbythevariousmedical
"units»the'budgetarystructuresofthepublichealthsectorasa
wholeiareconsideredbelow.Thefollowingcharacteristics arefound:
(a)Overallmeagrenossofthepublichealthbudgets
InmostStatesthegrowth "ofthehealthbudgetssincetheearly
1960s,expressedincurrentCPAfrancs,haslaggedbehindthe
growthofappropriations inthenationalbudget.Consequently ,
thehealthbudget'sshareoftheoverallnationalbudgethasfallen
considerably :inUpper.Voltafrom13*3%to1.2fa,inCameroonfrom
'6.6$to5»4and,lesssharplyinNiger(from8.7%to7*8%)
! _<_/_*^.___A _ 2andDahomey(from12.6%to10.5Theonlyexceptionshavebeen
Congo,IvoryCoastandMali,where(atleastupuntil1970)the
•':healthbudgetsgrewmorethanthenationalbudgets..
SeeChapterB,IV,page14etseq. *'*
Source:SEDES,preliminary studyonthetrendinhealthexpenditureinthe
■AfricanStatesandMadagascar-April1972.

-40- VI11/467/75-E
Accordingtothestudyreferredto,thehealthbudgets,convertedinto
constantCFAfrancs,havetendedtoremainstationaryinmostcountries... . 2(e.g,CentralAfricanRepublic,Madagascar,Chad)oreventodecline
(e.g.UpperVolta,;Jigei>jSenegal,Togo).TheonlyStateswithadequate
growthintheirhealthbudgetswereCongo,IvoryCoastandGabon.
DespitethegrowthinhealthbudgetsincurrentCPAfralncs,annualper
capitahealthexpenditurehasfallen,fortheStatesexamined,toa
.currentlevelofbetweenCFAF165(UpperVolta)andCFAF650(Cameroon),
2withanaverageofCFAF330-450(Madagascar ,Somalia,Mauritania,
Dahomey).Thereappearstobenocorrelationbetweenthislevelof
averageexpenditure andthehealthbudget'sshareofthenational
budget#whichvariesfromonecountrytoanother,e.g.below6foforCameroon
•andMauritania,between6foand8foforUpperVolta,SomaliaandNiger,
andover10foforDahomey.
We ;can addthatappropriations foreducationinanumber
ofcountriesaregreaterandgrowingfasterthanhealthappropriations
(e.g.UpperVolta,Niger,Dahomey,Gabon,IvoryCoast).
(b)Imbalancebetweenstaffandoperatingexpenditure
InalltheStatesexamined,thestaffbudget,asapercentageofthe
healthbudget,hasbeenrisingfairlysharplysincetheearlyI960's
andiscurrentlyaround50%inNiger,50foto60foinMauritania,
MadagascarandSomalia,75f°inCameroonandDahomey,and85foin
UpperVolta.
Theresultofthisisthatvirtuallyidenticalhealth'budgets(e.g.
NigerandUpperVolta)mayhideconsiderabledifferencesintheamount
ofthenon~staffoperatingbudgets(fourtimesgreaterinNigerthan
inUpperVolta)andpercapitaoperatingexpenditureforhealth(five
timeshigherinI'igerthaninUpperVolta).
l$eefootnote(page39)
2Centralhealthbudgetalone,withoutaccountbeingtakenofthe
substantialhealthbudgetsoftheProvinces.

-41– VII1/467/75-E
'Consequently ,-thankstothereasonabledistribution ofitshealthbudget
-'(approcimatelyhalfearmarked "for,operatingexpenditure )Ijiger.seemsto
•beinabetterpositiontoensure,byitsownresources*'thatitshospital
facilitiesareproperlyrunjimUpperVolta,however,because,-ofthe-low
(-.operatingappropriations .(15$)»thereisafundamentalimbalancebetween
.thefinancialrequirementsofexistinghospitalsandtheir.ownresources.
vAnothercomparisonshould ^bemade?theratioofhoepiiil.beds toinhabitants
is'faifrlylowinbothcountries:onebedper1430inhabitantsinHiger ,
andone-bed.per2210inhabitantsinUpperVolta.Althoughthereisa
-betterbalanceinrfigerbetweenexistinghospitalinfrastructure andthe
■oountry'swn*financialresources,>theratioofbeds,topeopleinUu&rVolta
although low–stillseemstobehigherthanwould,beexpectedfrom
theappropriations earmarkedforoperatingexpenditure.;'...
(c)Meagrenessoflocalauthorityappropriations
InvirtuallyallthoStates,thelocalauthorities meetpartofthemedical
establishments 'runningcosts.Ingener&l,howeverithese'financialcontri­
butionslackcontinuityandareirregular;besidesinmostoftheFrench-
speakingStatestheamountsinvolvedseemtobequitelow.InUpperVolta
forexample,thetotalamountmaybeestimatedatapproximately 10$of
thecentraloperatingbudgetforhealth.InMadagascar,ontheotherhand,
thebudgetsoftheProvincesincludeconsiderable appropriations forhealth,
■almostreachingtholevelofthenationalhealthbudget*.
In1972,atotalofCFAF4319millionwas.providedforpubliohealth
spending,ofwhichCFAF2319millionfromthebudgetandCFAF2000
millionfromallthebudgetsoftheProvinces.

-42- VIII/467/75-E
(d)Imbalance between expenditure oncurative medicine andonpreventive
medicine
Intheabsence ofadequate andprecise information allthat canbesaid
isthat there isageneral tendency foracountry 'sappropriations for
preventive medicine tobeextremely loi*.InCameroon ,forexample ,ofthe
1974/75operating budget forhealth (CFAF 1-223million )only 1.3 fo
wasearmarked forpreventive medicine and3^tocover thewhole ofrural
andpreventive medicine andthecampaign against epidemics .Thesituation
iscertainly nobetter inother countries .Itmaybeestimated that pre­
ventive medicine should actually receive about aquarter ofthebudget for
ittobeable tofunction props ?ly.Thereal situation isvery different :
'itiscurative medicine and ,more particularly ,certain hospitals which
arethebigconsumers ofbudgetary ressources .
(e)Inequality between bigtowns andrural areas intheallocation' offunds
Theinformation obtained onhealth budgets hasnotenabled theshare
offunds earmarked forhospitals inbigtowns tobedetermined .However ,
thepreference given tourban centres derives from theconcentration
ofhospital facilities inthebigtowns andtheamounts earmarked in
thehealth budgets forthebudgets ofthegeneral hospitals .
-.Generally speaking ,hospital capacity islargely concentrated in
thecapital ?forexample inUpper Volta less ,than 5$ofthe
total population ,living inOuagadougou andBobo-Dioulasso ,enjoy 56
ofthecountry 'shospital capacity .Thecorresponding figures
are,forNiger (Niamey andZinder ):4%and39/£sandforSomalia
(Mogadishu ):.10%and50$•-
V

-43- VIII/467/75-E
-• k«
..._.1.2Therelationship betweenoperatingfundsspentbythegeneral
hospitalsandhealthbudgets (<perating)clearlyhighlightsthedegree
:ofconcentration andthe:difficulties .whichmayresultforthe
financingofacountry'shealthinfrastructure .
Thenationalhospitalin.Nouakchott (Mauritania)absorbs35foofthe
fundsavailableforoperatingexpenditure andthetwonational
hospitalsinNiameyandZinder(Niger)takemorethan40fain
Nigerthetwohospitalsandfivesecondary-level hospitalcentres
,receiveatotalof535°ofthenationaloperational budgetfor
health.InUpperVolta,thetwo.generalhospitalsinOuagadougou
and3oboDioulassorequirenearly40moremoneythanprovidedfor
ir^thetotaloperatingbudgetforhealth*Thebudgetsforthetwo
......secondaryhospitalsinGfaoua.andFadaN'Gourmawouldtogetherabsorb
,nearly50f°ottheoperatingbudgetforhealthiftheywerecharged
againstthatbudget♦
(3)Externaloperatineaid
Tosuraup,inmostcountriesthereisafairlymarkedimbalancebetweenown
financialresourcesandactualrequirements ,Itisonlytheoftenconsiderable
contributions -financialandinkind-fromallkindsofoutsidesources
whichenablehealthunitstooperate'properlyandcertainobjectivesinthe
fieldofpreventivemedicinetobeattained.
Operatingaid.fromoutside^,takenasawhole,isofgreatimportanceforUpper
Volta,MauritaniajITiger,ChadandDahomey,ofmediumimportanceforCameroon,
SenegalandMali,andofslight -importanceforTogoandIvoryCoast.
1 · ..Therelationship betweenthegeneralhospitals'staffbudgetsandhealth
staffbudgetsisnotindicativesincemostdoctorsonthestaffcometinder
outsidetechnicalassistance;theremuneration ofthosedoctorsisnot
thereforechargedagainstthesebudgets.
2Actualexpenditure,irrespective ,oftheoriginofthefunds(expenditure
asdefinedinChapterB,IV,1,page14)•
^Thqyarebp-mealmostentirelybyGermanaidandaidfrom"FreresdesHommes".
4 .AccordingtotheSEDESstudy.

44- VIII/467/75-E
Externaloperatingaidcomesfromvarioussources*ofwhichthemain >
onesare:. ■■■ '-'■<•-
'-iofficialbilateralandmultilateral aid,e«g.French,German,
Belgianaid,etc.,eitherpertainingtotheoperatingunits
(medicaments,equipment,vehicles,etc.)ortocampaignsto
combatandwipeoutendemicdiseases,etc.Suchaidoften
providedthelogisticback-upforthetechnicalassistance
personnelonthespot;-
Americanaid(AID)relatingtoregionalornationalprogrammes:
maternityandchildhealth,programmestowipeoutsmallpoxand
measles,educational andhealthenvironment programmes,food
aidprogrammes,etc.; -.<
IIHOandUNICEFaiddealingwithspecificcampaignsandprogrammes >
forexampleto'combatendemicdiseases,toimprovesanitation,etc,}
-privateaidfromallsources^,particularlyphilanthropic ,religious
torganisations ,etc.'
(4)Lessonsdftawnfromanalysisofpastexperience
VHiatlessonsaretobedrawnfrom&hexaminationofexistingsituations?
Whatarethecriteriaforassessingthefinancialaspects,ofaproject?
;Withreggxdtothepreparationandplanningofnewprojects,thefollowing
pointsshouldbetakenintoaccount:
(a)Tobeginwith,thebalanceorimbalanceexistingbetweenacountry's
ownfinancialresourcesandthefundsrequiredtoruntheexisting
healthfailitiesshould ,beexaminedandassessedonthebasisof:
./•
SeealsoChapterB,IV,3,page.17.

-45-.Vil1/467/75-E
-»'the-health1"budget,itspasttrend,thefwayinwhiph,itis
sharedotitamongthevariousactivities(curative,preventive,
medicine/etc.),How,itisdistributed"amongthevarioushealth
unitsaridinparticular -the-hospitalsatdifferentlevels,the
localauthority'budgets?' >
theamountsspent^byexistinghealthunitsatdifferentlevels,
theirpasttrend,theoriginofthoseresources,inparticular
externalfinancialandotheraid.
(b)Evaluationofthecontinuityandregularityofexternalaidandlocal
authoritybudgetsenablesanassessmenttobemadeofhowstablethe
balanceachievedis.Evaluationofthevolumeofadditionalrecurrent
'chargesresulting ,fremtheplannedinvestmentmusttakeaccountofhow
delicate such,balanceisorislikelytobe,
(c)Thedangerthatfullusewill.notbemadeoftheinvestmentincreases
inproportiontohowmarkedthe'actualimbalanceis,thatistosay
howthede-factobalanceisdelicate.
(d)If,whenaprojectisbeingplanned,itisalreadyforeseeablethat
the,beneficiarycountrywillnotbe.inapositiontoooverthe
operatingcosteitherfullyorinpartfromitsownresources,there
arefoutfpossibilities :•.". v';
-theprojectshouldbeabandoneds
■i-theprojectshouldbescaleddowntothecountry'scapacityto
ensijrethatit'isoperatedproperly}perhapsfullexecutionof
-theprojectshouldbephaseds
theGovernmentshouldtakeappropriate measurestoimprovethe
actualfinancialconditionsofoperations
•A
Actualexpenditure,irrespectiveoftheoriginofthefunds(expenditure
asdefinedinChapterB,IV,1,page14)

-46- VIII/467/75-E
-operatingcostsshouldbemetinfullorinpart"byexternal
aid.
TheGovernment mayhereexaminewaysoftakingappropriate measuresat
nationalleveltoincreaseitscountry'sownfinancialresourcesby,
forexairple:
-increasingthehealthbudget'sshareofthenationalbudgetj
-increasingtheamountearmarkedinthehealthbudgetforoperating
expenditure (theoptimumseemstobearound50/^)5
-studyingpossiblewaysofgraduallybringingthepopulation
tobearcertainhealthcosts:increasingthescalesofhospital
charges,examiningpossiblewaysofgivinghospitalsfinancial
autonomy,saleofmedicaments ,etc.
Governments mayalsoendeavourtoobtainforeignaidintheformofstaff
andfunds?theexampleoftheMogadishuhospital(Somalia)does,
however,showthatitisveryimportanttoevaluateanysuchconditions
adoptedasabasisfortheplanningofaproject;itisusefultotake
precautions toensurethat,:\i£Aidifromoneormoresourcesisreduced
orfailstomaterializeetall,thiswillnotmeanthattheproject
cannotoperateproperly.Finally,externalaidmaybeusedtocover,
the.oostofstartinguptheinvestmentatleastduringatransitional
period# ■>.
(e)Forthepoorestcountrieswhicharealongmybehindintheirhealthdevelop­
menttheexternalaidbodiesmightevenconsiderexaminingthepossibilities
ofproviding,attheirexpense,certainpartsofthecurativeorpreventive
healthservices.

VIII/467./75-"1
(f)Finally ,there isa.question ofprinciple :isthedecision to
undertake acr,~)ital project inthehealth sector well-founded ?
Might notthealternative -toincrease theoperating funds for
preventive medicine –bemore beneficial torthe "health situation
ofthepopulation ?

VIII/467/75-E
Technical design
Inview ofthescope ofthis report only afewgeneral remarks canbemade
regarding thetechnical aspect ofproject planning andthelessons which
can belearnt from thorn . •
(l)Criteria foradapting projects torequirements
(a)Buildings andecruiprnent
Inspite ofoften inadequate oreven non-existent upkeep *thebuildings
proper ofmost medical units areinrelatively good condition *However , .
theinteriors (plaster ,paintwork ,door-frames ,etc .)areless sound .
Very generally ,it hasbeen proved that buildings ofsimple ,modest
.androbust construction ,adapted t>local conditions ,have given the
best results .This istrue ofboth traditional constructions and
prefabricated buildings .
,Ithasbeen found ,however ,that inallhospitals atalllevels the
more complex orsophisticated thefixtures ,thefaster they deteriorate
orbecome unusable even (forexample :electrical ,refrigerating ,
telephone andheating installations ,-lifts ,electric pumps ,air
conditioning plants ,etc.). .
Thesame istrue ofmedical equipment ,which often seems toospecialized
andill-suited forthemedical personnel onthe spot endconstitutes
theweak link inmany investment schemes .
(b)Complementary investments
Experience ofthefirst fewyears revealed that itisoften risky
tohope that complementary investment ^(road infrastructure ,laying
onofwater andelectricity ,,staff accomodation ,enclosures ,etc.)
andmedical equipment will befinanced andprovided bythenational
authorities aslaiddownintheFinancing Agreements ^".Consequently
fcrmore recent projects theCommission hasavoided part-financing ,
inother words ithasavoided leaving thenational authorities with
responsibility forfinancing parts ofprojects »
However ,ithasbeen found that local authorities have sometimes financed
andundertaken certain complementary schemes because the
•A
Seeinparticular thecases referred tointhevarious reports 6n
theutilization ofaidt inChad(1969»p.44-45 )»Mali(1970,p-32),
Burundi andDahomey(1971,p.3-3-39).

•49- Vin/467/75-E
•v i.
project asinitially conceived hadturned outtobeill-suited to
local needs andthepopulation 'scustoms andhabits .Themost frequent
cases arethefollowing :
-Inmany cases itsoon becomes difficult ,ifnotimpossible ,to
"use tliesanitary facilities (WCs,showers )because ofobstruction ,!
ofthewaste pipes andtrouble with theplumbing .Those res­
ponsible have therefore closed facilities incorporated inside
buildings andconstructed traditional facilities outside (e.g.
Garoua andFada F'Gourraa secondary hospitals in-Upper Volta ).
These problems hardly arise inthegeneral hospitals butare
quite common inthelower-level health units inrural areas .
■ .Experience has shown=that itwould often besufficient to
provide alimited number ofsuch facilities fortheuseofthe
staff andsome patients whoarealready accustomed tothem .
'•.wInthehealth unit& inrural areas ,thekitchens (which operate
inafaifcly normal ,fashion inmost general hospitals )areoften
replaced bytraditional stone hearths setupoutside ,forthe
• following reasons :lack ofoperating (fuels )andmaintenance
•funds ,differences ineating habits andcustoms (preference
.forfood prepared byaccompanying relatives ).
Similar problems arise regarding thelaundries' .Where the
installed machinery isoften unused because oflack ofwater ,
electricity ,fuels orsimply operating funds .'
«-The accomodation constructed for those accompanying patients
aresometimes used forhospitalizing those with contagious
diseases (e.g. .Garoua ,Upper Volta )}asaresult thenational
.authorities have constructed traditional type huts better
suited tp^ocal requirements .Special attention ^must ,however ,
bepaid tostaff accommodation ,particularly inrural areas ;

-50- VII1/467/75-ïï
theprovision ofstaff accommodation helps toeliminate
oneofthecauses ofhigh staff turnover ,reinforce the
*
staff 'sauthority andinfluence ,andensure better upkeep
ofthe "buildings andoftheinstallations into health units .
(c)Summary
Ahealth project must normally "beconceived insuch a.wayastotake
account ,ontheonehand ,ofthemedical services tobeprovided ,and
ontheother ,ofthecost oftheinvestment andofthetechnical ,
financial andstaff resources available foroperating andmaintaining
both infrastructure andequipment .
Imagination must beshown inadapting buildings andequipment to
available financial resources ;inshort ,ananswer must befound to
:thequestion ofhowtoprovide modern andefficient medical services
with limited resources .
Thetechnical design oftheproject should betailored totheusers'
level ofeducation , .real requirements and iway oflife
inthearea concerned# Without going totheextreme of
anAlbert Schweitzer-type approach forexample -forwhom thepatient
should find mirrored inthehospital theenvironment ofthevillage
hecomes from –acompromise formula might befound inwhereby the
hospitalized patient finds anenvironment which does notmake him
feel too much outhisownelement .
Moreover ,itisparticularly important "totailor aproject tolocal
conditions andthepopulation 'sstandard ofliving inthematter of
fixed installations andmedical equipment andalso complementary
"investments (accomodation ,kitchen ,laundry ,etc.).

-51- vu1/467,/75-r
However,anynecessaryadaptationtolocalneedsoftenconflictswith
thenationalauthorities'desiretohaveSuropean-type buildingsand
themostup-to-dateequipment.Insuchcases,itisnotenoughto
takeappropriate stepstoensurethattheinstallations andequipment
-*'aresuitablymaintained.Oftenageneralsimplification ofthedesign
isstillnecessaiy..
(2)Someconsiderations ontherequirements astotechnicaldesign
(a)Flexibility
Inordertobeabletofollowthetrendofallthefactorswhichmighthave
abearingonthedesignofahealthunit(trendofthepopulation's
socio-economic conditions,progressinthetechnicalmethodsofmedical
treatment,etc.)theessentialcriterionthedesignmustmeetisthat
flexibility.'.Jhilesophisticated designsshouldbeavoided,thedesired
flexibility should,attheplanningstage,bereflectedinthefollowing
characteristics :
""extensibility,throughthechoiceofthepawilionsystem,whichhas
-,l.valreadybeenadoptedinmanyhealthunitsfinancedbytheEDFand
"whichisgenerallynecessaryeveniftheneedtointegratebuildings
~intoanurbansitemaytosomeextentjustifydifferentarchitectural
parts(e.g*intheInstitutNationalde-SantePublique,Abidjan)}
–interchangeability,throughtheuseofappropriatestructuralmodules
permittingmulti-purpose utilization ^
-transformability ,bymeansofeasyaccesstopipes,forexample,
topermischangesinconnectionstothemains*etc.
(b)Construction requirements
Theabovecriteragiverisetocertainconstruction requirements »
themostimportantofwhichmaybesummarizedasfollows:
–Thesitemustbechosenbyreferencetofutureextensions,
typeofsoil,waterandelectricitysupplies,waste-water
drainage,accessibility forthepopulation,etc*

-52- VIII/467/T5-S
Effortsmustbemadetoohooseanarchitectural solution
whichispsychologically adoptedtothelocalpopulationso
thattherisersareencouragedtotakeonresponsability for
maintenance. , .
Theohoiceofstructuresmusttakeaccountoftheflexibility
ofoperatingandclimaticconditionsandofthecapacities
ofthelocalmarketandlocalfirms,etc.Standardization by
meansofaprefabricated system(Niger,UpperVolta)hasproved
tobeparticularly usefulif■
,alargecomprehensive projectisinvolved(witha
sufficientnumberofhomogeneousbuildings)
.itenablesbuildingstobeconstructed morerapidlythrough
betterorganization ofthebuildingsite-sandexecution }
.itcanguaranteeworkofahigherquality;
.itcanguaranteeaninvestmentcostequaltoifnotlower
thanthatoftraditional constructions !
#iicanfacilitatesubsequentstructuralorfunctional
modificationsí
.itenablescurrentmaintenance expendituretobereduced.
However,theadvantagesofstandardizing structurescanbeachieved
onlyifitisguaranteed^whentheprojectisundertaken,that:
,theplansanddesignofthebuildingsandequipmentare
wellharmonizedandcoordinatedrightfromthebeginning
inordertoensurecoherenceofthebuildingandequipment;
•thebuildingschedulesanddeliverydatesforequipmentare
coordinatedinordertoavoidinterruptions intheexecution
oftheproject}
•importedsupplies(prefabricated partsandequipment)are
notfaultyanddonotgiverisetodelaysaffectingassembly
andthebringingintouseofequipment.
Materialsmustbechoeenbyreferenceto:
,climaticconditions !
stherequirements ofeasymaintenance,cleaningand
replacement ;

-53- VII1/467/75-B
«v
«anyeffectsonthelocaleconomy(utilizationoflooally
manufactured ,buildingmaterials).
' mf•».»'*''
-Fixturesandequipmentmustbechosenbyreferenceto
.•theuser(easytooperate);
•maintenancefacilities (resourcesavailableonthespotr
preferenceintheawardofcontractscouldbegivento
themakeforwhichtherearelocalagents;verystrictrequijreraentsinthespecifications regardingafters-salesservice)
ifacilitiesforobtainingreplacementparts;
* 2reasonableoperatingcosts•
SeeàlsoChapterB'tII,2.page9
Seealso1970reportontheutilizationofaid,pp«85-86

54 VIIl/467/75-3
Projectstoprovideoperatingaid
Thefollowingconsiderations arebasedonevaluationofthetemporaryaid
operationslinkedwiththeconstruction ofthehospitalinMogadishu
(Somalia)"''.Theseoperatingaidprojectsmayinvolve "boththepaymentof
staffcosts(technicalassistance)andoperatingexpenditure .
I.Technicalassistance
InMogadishuhospitalthepressureoftimeandthemultinational naturecf.;
*
thecoordiated SDP/bilateralaidoperationresultedinthemedicaland
ancillarymedicalstaffbeingaverymixedgrouphaving
.T
difficultyinworkingtogether.However,differencesoforiginandprofes­
sionaltrainingwerenottheonlycausesofproblemsaffectingmanagement
andcooperation ;multinational teamsareworkinginmanyotherAfrican
2hospitals •Iniibgadishuitseemsthat,becauseofthepressureoftime,
staffwasselectedandpostsfilledinasomewhatunsoordinated fashionfrom
themedicalpointofview.
Promthisexperienceitmaybeconcludedthattechnicalcooperation canonly
be*successfulwherethemedicalandancillarymedicalteamsarehomogeneous ,
.•coherentandhaveaninternal -.hierarchy;onlytheseconditio®Cjanguarantee
:theindispensable spiritofcollaboration ,mutualprsfessional respectand
theauthorityofthoseincharge.:Staffselectionandrecruitment cannot
thereforebecarriedoutwithouttheactiveanddecisiveparticipation of
;theheaddoctor. ■v.-.!' :
SeedescriptionAimezï/lletsecr.
InthehospitalinJTiameyforexample,thetwentysevendoctorsareof
sevendifferentnationalities ;cooperationdoesnotpresenttheslightest
problem•

?55- VIII/467/75-E
•f4 , - •• •
; .. **.*»<
II.Temporary financing ofrunning costs
After undertaking tomeet theMogadishu hospital 'srunning costs aswe11,.the Com .
munity adapted itsfinancial resources totheproject asinitially planned
(high degree ofmedical specialization ,very up-to-date medical equipment ,
European-type fixtures ,etc.).After external assistance progressively came
toanend itwasnotpossible tokeep operating atthis level ;the1973
operating "budget wasreduced by35 compared with 1966/67•Itisobvious
that this deorease inreal operating expenditure wasbound toinvolve either
ageneral reduction inthehospitals activities orareduction inthequality
oftheservices provided .However ,areasonable balance hasbeen created over
anumber ofyears ,atalower level ,between theacquirements oftheproject as
.originally conceived andthecountry 'sfinancial resources .
Past experience shows that operating expenditure must ' !
«<■betailored ,from theeutset ,tothecountry 'smedium«-terra financial >
, ... •;capacity (even at.therisk ofoperation being atalower level than
that provided forintheinitial plan ifthat plan wasnotrealistic );
thedanger must beavoided ofasudden break inthe level ofoperation
andmaintenance atthetime iof -,handing over ,orofcreating excessive '
1
'■* •expenditure tobeborne atthe .expense ofother health operations ;
•»-beplanned onadiminishing scale (aswasdone bytheSDP)inorder
toencourage thecountry 'sownefforts andensure that ittake over
running costs assoon aspossible . *
'' ' ' : **i■.. -!:■ '
Inconclusion ,itshould beborne inmind that anoperation toprovide technical
assistance andtemporarily running expenses :
•»
-maybejustifiable asanexceptional rescue operation where the
beneficiary country willW-in aposition gradually tobear the
'running costs andtak6 ever from thetemporary aid ;: t
_______ * ' * •
Period during which theoperating budget wascovered bytheEDF ;the
comparison takes account oftheincrease inthegeneral level ofprices .
2This condition issetoutexplicitly inthetext oftheConvention ofLome
(Article 58(2 )).

-56- VIII/467/75-E
maybe "beneficial tothecountry 'shealth development andreasonable
asaninvestment-linked technioal assistance operation inasmuch as
itcontributes :
•tothestarting upoftheproject under thebest technical
conditions ,
#toon-the-jobtraining ofnational doctors andancillary
medical personnel ,
,tothepreparation inthebest possible conditions andinas
short atime aspossible forthehanding over tonational staff ;
would ,however ,beofquestionable value inthat external aidwould
relieve thebeneficiary country ofresponsability forbearing in
full theburden ofadministration andmanagement of "theinvestment }
inthis case there isadanger that aidwould only defer theproblem
without helping tosolve it*

-57- VIll/467/75-2
S.SIM-iARYATOGEIT3RALCOl.'CLUBIWTS
1.Theprojectsreviewed ,chowthatinthepasttheCommunityhasconcentrated
onfixedhealthinfrastructure atalllevelsofthehealthpyramid,either
intheformofisolatedprojectsorofcomprehensive projectsintegrated
inhealthdevelopment programmes.Thecompletedprojectswhichhavebeen
evaluatedhavethereforerelatedonlyintheconstruction ,modification
andmodernization ofhealthunits(hospitals,healthcentres,dispensaries ,
etc.)^andtooperatingaidforoneofthoseunits,Mogadishuhospital
(Somalia).
2.Ingeneralthese,projectshaveledtoaconsiderable improvementinthe
countries'healthinfrastructure ,'lostofthefacilities financedareused
ataratewhichmayboconsideredsatisfactory .Someofthem,however,
intheintermediate andlowerechelonsofthehealthpyramid,havenot
beenusedtotheextentnormallyexpected.
Eventhoughtheactivitiesofcertainhealthunitsmaynotbeuptothe
objectivessetorthecapacityofthefacilities ,theirusefulnessis
nevertheless inmostcasesunquestionable .Alltheprojectsfinancedhave
enabledtheefficiencyoftheavailablehealthstafftobeincreasedand
treatmenttobemademoreaccessibletothesick.However,thecasesof
under-utilization maketheinvestmentcoststoohighinrelationtothe
servicesdispensed.
Ifsomehealthunitsarenotbeingfullyutiliied,thi3isbecausethey
lackadequateoperatingresourcesorinsomecasesbecausecertain
complementary conditionsarenotfulfilled,oreven,butmorerarely,
becauseoferrorsmadointheplanningoftheprojectorchoiceoflocation.
3.Thefirstprojectsexecutedwereinsufficiently utilizedowingtolackof
staffandofoperating 1andmaintenance funds.TheAASI4Governments and
theCommissionwerequicktorealizethedangerofprovidingtoomanymedical
facilitiesfortheavailableoperatingresources:whilehealthprojects
accountedfor9%offirstEDFcommitments,thispercentagefellto4^
forthesecondand3foforthethirdEDF.
TheEDFhas,moreover,financedonlyonemajorhealthcampaign:that
againstonchocerciasis (Mali,UiprVolta,IvoryCoast)

-58- VIII/467/75-E
Furthermore ,theoperating problems have diminished over theyears .The
recent establishment ofnewmedical faculties inAfrica will help solve
theproblems –which arestill very real -caused bytheshortage of
national doctors ,provided ,however ,that their salaries canbeborne bythe
health budgets ofthecountries concerned .With theopening ofanumber of
schools fortraining ancillary medical personnel ,thedirect requirements
forstaff ofthis category canbemetorsoon will be.Anumber ofprogrammes
fortraining maintenance staff ,launched attheC^mmissiott 1®insistence
andcarried outwith iuDFfinancing ,maybeconsidered aneffective and
practical solution totheacute problems ofmaintaining equipment .Never­
theless ,thecrucial problem remains thegeneral inadequacy ofthecountries'
ownfinancial resources ,particularly asregards operating funds ;this
shortage offunds reduces theefficiency ofthestaff intheunits ,
even ifthey areworking inbetter facilities andwith better equipment .
Examination oftheconditions inwhich completed projects financed bythe
SDFarebeing used shovis that ingeneral amajor higher ranking hospital
hasabetter chance ofbeing properly used andismore likely tobe
viable thai health units atthe intermediate and lower levels .The reason
forthis isthat Governments tend toconcentrate their funds ,staff and
equipment ontheformer ,which also satisfy the'needs ofnational prostige#
Thus provided with adequate funds andstaff (reinforced byexternal aid
where national resources arelacking ),themajor hospitals aregenerally
fully used :to90-100^oftheir theoretical capacity andsometimes
even beyond that .However ,theintermediate andlower-level units arevery
often notused totheextent planned because anuneven allocation of
operating resources works totheir disadvantage .Therecorded utilization
rateisbetween 40$and'70$forsecondary hospitals andhealth centres *.
SeeChapter B,I,1 ,p.5*

-59- VI11/467/75-3
Ingeneral,thefurthertheunitis»functionally andstructurally-from
thecentreofthings,themoredifficulttheoperating ,conditions become:
veryoftenruraldispensaries ar.edeprivedevenof,thqmostelementary
requirements (medicaments,etc.)?sometimestheyareevenleftemptyfor
longperiodsbecausethere,isnonurse.
5*Ahealthunitmay"beunderutilized eveiiifalltheinternaloperating
conditionsaresatisfactorily met;foranestablishment tobeableto
fulfilthefunctiondevolvinguponitwithinthehealthpyramidcertain
camiplementary conditionsmuststillbemet:adequateadmissionregulations ,
goodr»adlinkswiththecatchmentareaandbetweenhealthunitsof
differentlevels,availability oftransport,supportfromthepopulation,
etc. -
Consequentlyitisnecessarywhenplanningaprojecttoexaminenotonly
theoperatingconditionsproper,butalsothenecessarycomplementary
conditionsandpossiblewaysofimprovingthoseconditions ,forexample:
workingandlivingconditionsof'themedicalandancillarymedicalstaff,
amountoffinancialresourcesdevotedtohealthyetc.Onlyifmost
oftheseconditionsarorr.otinasuitablemannercanoptimumusebemade
ofeachandeveryhealthunit-providedofcoursethattheyhavebeen
plannedinarationalfashiori.' -;
UJ-."
6.Whatarethecriteriaforrationalplanningofsuchinvestments?A
country'shealthinfrastructure willoperaterationallyandeconomically
onlyifallitsconstituentpartsareharmoniously integratedwithina
coherentandwell-balanced whole.Thisassumesthat:
-thecharacteristics oftheinfrastructure willbeadaptedtothe
country'sfinancialandstaffresources 5
•/•
SeeChapterC,I,3,page30etseq.

-60- VI11/467/75-E
-hospitalswillbeorganizedonaregionalbasisinordertoreconcile
thepopulation'shealthneedswithstaffandfinancialconstraints ?
•allhealthunitsofdifferentlevelswillbeorganizedonahierarchical
patternfromthetechnicalandfunctionalanglesandwithregardto
specialization andcapacity.
Failuretoobservetheseprinciplesinvolvesdistortionsorimbalances
atnationallevel:overutilization ofsomeunitsandunderutilization of
others;preferential healthcanforsomepartsofthepopulationandneglect
ofothers*
7.Thevolumeofforeigncontributions offunds,suppliesandstaff,which
oftenalonemakeitpossibletoguaranteetheproperfunctioningofthe
healthunits/indicatesthegapbetweentheoperatingrequirements of
theexistinghealthinfrastructure -andthecountry'sawnresources.For
exampleexternalfinancialaidmaybeestimatedatmorethan300°Joofthe
nationaloperatingbudgetforhealthinUpperVoltaand40/*inNiger'*'.
Theproportionofdoctorsprovidedbytechnicalassistanceoutofthe
totalnumberofdoctorsamountsto35$inNigerandMauritania'.70$in
2UpperVoltaand40$inSomaliaandCameroon•
Whenanewprojectisplannedadetailedexamination mustthereforebe
madeofwhetherrunningcostscanbecovered«-bynationalresourcesor
dependableaid.Examinationoftheprojectwillalsoinvolveassessment
ofthemeasurestakenorplannedbyiienationalauthoritiesinore'erto
increasethecountry'sownresourceswhichcanbeallocatedforrunning
thehealthservices^#Ifthereisnowayofensuringthattheprojectwill
beproperlyrun,eitheritmustbescaleddowntowhatthecountrycanafford
*Estimatedvolumeofexternaloperatingaid(withoutstaff)
Upper-Volta :approx.CFAF400million
Niger :approx.CFAF200million
SeealsoChapterC,IIIf3,page43.
2_..._ ... ..■-' •SeeChaptersC,II,1,page33andB»III»2,page12.
SeeChapterCfIII,4»page46.

VIII/467/75-B
orefforts must bemade to .obtain thesame health objectives byappropriate
action inthepreventive medicine field ,
8.With regard tothechoice ofthe design andcharacteristics ofanew
building thesuccess oftheproject financed bytheEDFinNiger highlights
theneed toexamine possible alternatives (e.g. construction ofageneral
hospital orofseveral health units outside thecapital ;newbuilding or
modernization ofanexisting hospital ,etc.).
Inorder toavoid structural and functional imbalances atnational level
the choice must bemade with consideration for :
-thecharacteristics ofexisting .infrastructure ,notonly inthepublic
sector butalso intheprivate sector ;there were forexample tvery good
;o-.reasons forconstructing anational hospital inNouakchott butfor
deciding against anewgeneral hospital inNiamey ;
•.-thecountry 'smedium-term financial andstaff resources .
Thereplacement ofanout-of-date hospital isnotnecessarily thebest '
!solution .Repairs andmodernization maybemore advantageous since :
-they enable recurrent oosts andsupplementary staff requirements to
beadapted better toavailable resources ;
they mayreduce therisk ofcreating surplus capacity ,
9.Thetechnical design often reflects theambitious aims.v.u,' ofthenational
authorities .Inorder tobeable toprovide efficient medical services
with limited resources andtoimprove thechances efthose services being
•1 ' .«. ■ :'
V.
SeeChapter C»I,2 ,page 27etseq .andilnnex 1/17-19 »

-62- VIIl/467/75-E
run sraootly ,thedesign must beadapted notonly tothetechnical ,financial
andstaff resources forrunning andmaintaining those services butalso to
the level ofeducation oftheusers ,thereal health needs ,local conditions
andthepapulations standard ofliving .
From this angle thetechnical design must have sufficient flexibility
astoarchitectural solution ,structure ofthebuildings ,choice ofbuilding
materials ,fixtures andequipment ^".
10.Tosumup,where there isanexisting infrastructure which iswell distributed
geographically ,anewproject 'schances ofsuccess increase totheextent
that (aswasthecase inNiger )thevarious elements ofthehealth infra­
structure canbegradually adapted –inboth quality andquantity -tothe
requirements ofthepopulation .Theexistence ofadevelopment plan setting
outthevarious stages ofitsimplementation will facilitate such adaptation
andavoid structural ,financial andstaff distortions .Inview ofthevery
limited resources ofmost ofthecountries ,anyefforts toimprove ^modernize
andmake existing health infrastructure andequipment more effective must have
priority over newbuildings .
./•
SeeChapter C,IV,pages 48-53

VIII/467/75-3
11# The uneven distribution offinancial and other rosources and ofstaff in
favour ofbigtowns endtothedetriment ofboth rural areas andpreventive
medicine indicate thedirection which future guidelines could take ..Governments
arefully aware ofthese imbalances .However ,inspite ofthetheoretical
"priorities laid down intheir health policies ,preventive medicine andsocial
medicine would bevirtually non-existent inmost countries without support
from the various external aid sources .
Preventive medicine hasless spectacular effects butismuch more effective
since itattacks thevery causes ofdisease .
Onanational scale available resources should bebetter distributed ina
concrete andpractical fashion between curative andpreventive ,concentrated
anddispersed ,fixed rindmobile medicine .
12..Inmany countries (e.g. Upper Volta ,Niger ,Chad )social medicine isprovided
from health centres bymeans ofmobile teams .Thepurpose ofthese teams is
tocarry out ,inconjunction with oneanother ,thetasks of:
*detection :making contact with thebulk ofthepopulation topermit
thesystematic tracking down ofdiseased anddeficiencies *
*.prevention :talcing advantage «fthegatherings ofpeople togive
vaccinations systematically }
-on-the-spot treatment ofthose whoare found tobesick butdonotneed
V- +obehospitalized ;
-removal oftheseriously illtoahealth unit :
"*health éducation .
This kind ofsocial medicine ,although based onvery simple andrelatively
low-cost principles ,oannot ,howeer ,give positive results unless itcovers
thewhole ofthescattered population atsuitable intervals .Inpractice ,
despite often substantial foreign &id ,itdoes notattain allitsobjectives
because ofthegeneral shortage ofstaff ,means oftransport ,medicaments ,
vaccines ,etc .
./•

-64- VIII/467/75-E
13.Social medicine presupposesoperational andadministrative integration of
curative andpreventive medicine .
Operational integration maybeachieved byhealth-centres embracing arural
hospital orrural treatment centre (including hospitalization andoutpatient
departments )andmobile medicine services .Themost effective formula seems
tobeversatility ,providing all-round andcomplete health protection within
agiven unit ,namely care andprevention ,health education ,maternity andchild
health ,hygiene measures ,etc .Moreover ,itenables very rational usetobe
made ofmedical staffj doctors aregrouped together inhealth centres andcan
take responsibility forandsupervise lower-level establishments (rural centres ,
dispensaries ,etc,)andmobile medicine .
Inorder toavoid operational straims oranomalies ,administrative integration
ofresponsibilities isnecessary atthehighest level ,inether words within a
directorate oftheKer-lth Ministry .This integration isjustified bytheimpera­
tives ofelaborating health activities ,planning themethods applied and
distributing financial andstaff resources asrationally aspossible .Moreover ,
thesystems ofreicrcncc andsupervision must bestrictly determined atnational
level ,forwithout .this there isadanger that integration eftheoperations
themselves maybesideti'acked tofitinwith theinitiatives ofeaoh head doctor
,responsible . . .
14.Integration ofcurative andpreventive medicine athealth centre level must
besupplemented by .health ,education ;inparticular measures must betaken
topromote hygiene ,toprotect ofmother andinfant ,andtocombat malnutrition *
Health education isboth complementary -tocurative andpreventive medicine and
also thecondition upon which -theeffectiveness ofthetwoforms ofmedicine
depends .Anyhealth operation risks notbeing fully effective unless itis
accompanied bythesupport ofthepeople ,bycampaigns toinform them onthe
causes ofdisease andsimple andpractical methods ofavoiding disease fand
byimprovement ofthematerial living conditions upon which thehealth situation
depends .
Health projects therefore depend partly onother development Bchemes dealing
with agricultural development ,water supply anddrainage ,andtraining .
-/•

–65– VII1/467/75-£
In'conclusion ,anyhealth development policy orplan ,any investment in
health infrastructure andanyaction inthe field ofhealth must fit
harmoniously into the country 'ssocio-economic context and the general
development plan .
Thechoices tobemade inthehealth field could bebased onthefollowing
criteria :
uinorder tomaintain orachieve acoherent ,balanced infrastructure
and toavoid distorsions ,theprinciples ofasuitable degree of
regionalization .and •rganizdbi.on onhierarchical lines must beobserved ;
installations andequipment must beadapted toacountry 'sfinancial
andstaff resources ;arational increase inthese various resources
must beprogrammed onafaitly longterm basis ;such resources must bealso
allocated onareasonable regional andhierarchical basis *
allthehealth activities (curative ,preventive ,educative )must fit
into acoherent ,systematized framework made upofallthecountry 's
health services ;
wtoprevent thoimbalances infavour ofurban areas becoming more
marked itseems advisable fortheobjectives ofexternal aidtobe
oriented asamatter ofpriority towards strengthening allhealth
services inrural areas : ■ .
#either bysetting up#rimproving units (rural centres )which can
beused asabase forintegrated health measures ;
,orbydiroct aidtointegrated social medicine measures (campaigns
against endemic diseases ,detection andprevention campaigns ,etc.).
health education measures ,measures tocombat malnutrition andto
promote theprotection ofmother and infant arevital asacomplement
tohealth infrastructure investments .
_water supply andwaste water disposal programmes areparticularly
important inthat they contribute toimproving general conditions
ofhygiene :drainage project (waste water disposal ,etc.)mayhave
more beneficial effects onapopulation 'sstate ofhealth than

-66- VII1/467/75-S
ahealth Project proper .
-staff training must .tieinwith thedevelopment ofinfrastructure and
thevarious health projects inorder toensure that !
.anadequate number ofmedical andancillary medical staff isavailable
ingood time ,
staff qualifications areadapted tospecific local requirements ,
particularly tothespecial requirements ofsocial medicine and
health projects inrural areas .
■ where health projects (inparticular health programmes )arefinanced
byexternal aid ,better coordination ofsuch aidwould beUseful ,One
maywell askwether this coordination canbeachieved bytherecipient
State alone }efforts bythevarious international organizations themselves
andthedonors ofbilateral aidmight perhaps make the operations under­
taken more effective .
External aidinthefield ofhealth isundoubtedly aduty imposed byhuman
solidarity andalso apolitical necessity .Integration ofsuch aidinnational
economic andsocial development efforts istherefore allthemore necessary .
Improvement ofthepopulation 'sstandard ofliving bywell-balanced economic
development will toalarge extent provide solutions totheproblems which
health projects alone cannot resolve .

VUl/467(Tî)-E
Ori;..
AiTNEXl/l
THEPROJECTS
Objectives ,designandt~encrairesults
l)ProjectsundertakeninMadagascar
Thecommonobjectiveofthethreeprojectsfinancedfromtheresources
ofthefirstEDFinMadagascar wasthereplacement ofapartofthe
existinghospitalinfrastructure whichhadfallenintodisrenairand
becomeoverloaded.Theseprojectsinvolvedtheconstruction ofahospital
pavilioninMajunga,anewhospitalinManakaraandthefirstpartofanew
hospitalinPortDauphin.Theusebeingmadeofthesethreeprojectswas
examinedin1974*
(a)HospitalpavilioninMajunga
Theprojectfortheconstruction andequipmentofahospitalpavilion
inMajunga\whichwasdecidedonin1961,wasdesignedtoreplace
apartoftheoldhospital(100beds),whichhadfallenintodisrepair
andbecomeunusable,andtocarryoutasimultaneousextension(100
beds)ofthehospital.Thecapacitywastherebj'increasedto550beds,
.corresponding totherequirements ofthisgeneralhospital,which
coversawholeprovince.
Thearchitectural designofthethroe-storey building,whichcameinto
servicein1965,hasprovedparticularly successful.Thebuildingis
inagoodstateofmaintenance andalmostalltheequipment,which
hasbeenwelllookedafter,isstillinservice.Theavailablemain­
tenancefundshaveuptillnowenabledallnecessaryworktobecar­
riedout.
Theactivitiesofthishospitalshowthatitcorresponds verywellto
thepopulation'srequirements .Thenumberofpatientshospitalized
andhospitalization daysisconstantlyincreasing.Theoccupancyrate
increasedfrom77f°1968to91i°in1973*Inaddition,therehas
beenadropinthenumberofout-patients asaresultoftheopening
2andimprovementofthedispensaries inthetownofBlajunga.Outofa
totalstaffof170,thereare11doctorsand52nursesandhealth
assistants ,andanumberofthedoctorsandnursingsistersaresupplied
byFrenchtechnicalassistanceschemes.Thenumberofancillary-medical
andauxiliarystaffmustbeconsideredinsufficient .
•/•
(1)Expenditure :382.000u.a.
(2)Dispensaries runbymissions,semi-official orprivatebodiesorbythe
State.

1/2 VHl/467(75)-E
Theoperatingbudget(staffexcluded)ofthehospitalseemstobebarely
sufficient.Expressedintermsofoperatingcosts(l)perbed(H5G105.000)
andperdayfehospitalization (BIG260),theoperating "budgetisroughly
ofthesamescalethatofthesimilarcapacityhospitalsinOuagadougou
(CFAF116.000andCFAF390)andBoboDioulasso(CFAF125.000andCFAF350)
andconsiderablylessthanthatofthehospitalsinMogadishu,Somalia
(CFAFI85.OOOandCFAF5^5)andZinder,Niger(CFAF157»000andCFAF450)*
Thehospital'srevenuefromthe20$ofthehospitalizedpatientswhopay
fortheirtreatmentmust"bepaidtotheTreasury*
Tosumup,theusefulnessoftheinvestment made"bytheEDFisundeniable,
andtheattitudeofthepopulationisrelativelyfavourable.Theonly
impedimenttotheuseofthisprojectisageneralshortageofmedicaments.
(b)HospitalinManalcara
Theconstruction andequipmentofanew100-bedhospitalinIlanaltara,
withthepossibilityofextendingthecapacityto150beds,weremeanttomake
itpossibletoreplaceandslightlyincreasethecapacityoftheold
■hospitalinstalledin1930inalreadyantiquatedpremises,whichwere
supplemented in1952byamoremodernpavilion,andsituatedover3km
fromthetown.Theobjectiveoftheproject(2),whichwasdecidedonin
1961,wastotransferthehospitalinstallations intothetown.Conse­
quently,preferencewasgiventotheconstruction ofanewhospitalin
thetowncentreratherthantothemodernization oftheoldone..
i ■ . '',
Thegoodgeneralappearanceofthehospital,whichenteredservicein1967,
reflectsthesatisfactory generalmaintenance.Themaintenance ofthe
medicalequipment,however,posesproblemsbecauseoftheshortageof
qualifiedstaffandthelackoflocalrepairfacilities.
Theactivitiesofthehospitalusedtobecompletelysatisfactory ,but
havebeendistinctlyfallingoffforoneortwoyears.nowasaresultof
adeclineinthehospital'sreputationwiththepopulation.Asaresult,
■-A
(l)Figuresfor1973»and1975Zinder.
(2)Cost437.OOOu.a.

1/3 VIIl/467(75)-E
theoccupancyratefellfrom73in1972to417°in1974»atrend
accompanied howeverbya50aJoincreaseinthenumberof.patientshospi­
talized.
Thetotalstaff,allofwhichisMalagasy(55including
5doctors),seemstobesufficientforthis150-bedhospital.Theopera­
tingbudget(staffexcluded),whichislowerthantheestimatesmade
whentheprojectwasdesigned,isinsufficient ,hencetheneedfor
variouseconomymeasures(restrictions onlighting,useofvehicles,
etc.).
Tosumup,theoperationofthehospitalisrelativelysatisfactory in
spiteofthelowleveloffinancialresourcesavailable.Theobjectives
ofthisprojectcanbeconsideredtohavebeenachieved.Theoneblot
isthefactthattheoldhospitalhasnotbeencompletelyclosed.In
spiteofitspitifulstateofdisrepairandsordidfittings,theold
pavilionisstillbeingused(50'bedsforcontagiousandchronicpatients).
Administratively itisattachedtothenewhospitalandservedbythe
samestaff,but,becauseofitsseparatelocation,itisoutsidethe
normalcontroloftheheaddoctor.
(c)HosrjitalinFortDauohin
Theobjectiveoftheprojectfortheconstruction andequipmentofthe
firstpartofanew96-bed .hospitalwithsurgicalblockinFortDauphin
wastoreplaceaunitthathadbecomeunusableasaresultofatornado.
Thedesignofthisproject(l),whichwasdecidedonin1961,madeprovi­
sionforthepossibilityofasubsequentenlargementtoa150-bedcapa­
city.Toreplacetheoldhospital,whichwassituatedintheEuropean
residentialquarter,asiteneardistrictsinhabitedbytheMalagasy
population waschosen.
Becauseofthealmostcompletelackofmaintenance ,thehospital,which
enteredservicein1967»^advancedstateofdeterioration
(brokenwindows;cracksbetweenposts,beamsandpartitions ;doorand
windowframesbadlyrusted,etc.).Becauseofthe.shortageofqualified
technicalstaffandfinancialresources,themaintenance andconditionof
thefixedinstallations andmedicalequipmentarealsoposingmajor
(l)Cost:483«000u.a./.

1/4 VIII/467(75 )-E
problems .Thefollowing items have "been outofservice foralong time :
12outof13air-conditioning unite ,thelift ofthetwo-storey building ,
therefrigerating installations ,theemergency generator ,part ofthe
medical equipment ,etc.
Because .ofthepoor condition ofthehospital ,aggravated ,byageneral lack
ofcleanliness andhygiene ,thepossibilities ofusing itarefairly limited
(i.e. ,asregards thequantity ,quality andcomplexity ofthetreatment
given )* This situation isinevitably reflected inthe
figures onthehospital 'sactivities i21fooccupancy in1973 and39i°
1974 ,with ainaverage period ofhospitalization offive toseven days .
Thetotal staff complement (46including four doctors )issufficient for
acapacity of120beds (thesecondary hospital inGaoua inUpper Volta ,
bywayofcomparison ,hasastaff of50including three doctors ).Thestaff
complement isamply sufficient forthelevel ofactivity (less than 100
internal andexternal consultations perday). .
Thefigures available ontheoperating budget (staff excluded )axenot
conclusive *,Thefunds allocated in1973/74were relatively high tomopup
thedeficit ofthepreceding years .However ,itisfairly surprising tosee
that thebudget ofFort Dauphin (IMG17«5 million in1974 )isalmost ashigh i
that ofManakara (CFAF 15.0 million in1974 )inspite ofthelatter 'sgreater
capacity ,andlevel ofactivity .
Theusefulness ofthis investment hasoften been questioned ,since at
Manambara ,23kmfrom Fort Dauphin onanasphalted road ,there hasbeen a
Lutheran mission hospital inexistence since 1954 *Experience hasshown that
itisunrealistic toseeanaffront tonational prestige intheexistence
ofaprivate foreign hospital -thepick apeindifferent to .notions of
prestige .Theundeniable success ofManambara (l)constitutes both thecause
andtheeffect ofthefailure oftheFort Dauphin hospital .Itisalso a
fact tliat thepaying clientele prefers Manambara ,despite thehigher level
ofcharges (2).Even civil servants donothesitate tohave treatement at
Manambara ,even though inprinciple this isnotallowed .
(1)Capacity :57beds ;occupancy :approx .100 Staff :American Lutheran
missionaries ;budget ;RIG40million (l973)j 95%oftreatment ona
payment basis .
(2)Thehospitalization charge islower than atFort Dauphin ,butoperations
must bepaid for.

1/5 VII1/467(75)–E
,2)HealthunitprojectsundertakeninDriior.ey
InDahomey,Communityaidhasfinancedtheconversionofthehosoitalin
Parakouintoasecondaryhospital,theextensionofa,smallhealthunit
inSavalouandtheconstruction ofamaternityunitinAthieme.The
totalcostofthesethreeprojects,v:hichweredecidedoninI960and
carneintooperationbetx^een1964and1966,amountedto643»000u.a.
(firstEDP),
(a)SecondaryhospitalinParalcou
Thepurposeofconverting .thePara'couhospitalintoasecondary
hospitalwas:
-toremedytheseriousshortageofoperatingequ.ipr.entin
theonlyhospitalcentreinthenorthernregionswhich
co\;ldofferspecialized medicaltreatment ;
-tosatisfytheregionalhealthrequirements andtoreduce
thenumberofcaseswhereseriouslyillpatientsweretal:en
tothealreadyoverloadedhospitalsinthesouth.
Thisproject(l)increasedthehospitalcapacityby60bods,
to190,Itinvolvedtheconstruction andequipmentofnewbuildings
forsurgeryandtheextensionandequipmentofthematernitywing.
Thishospitalconstitutedthemainsupportforthehealthprogramme
inthenorthofthecountry,aregionwithmorethan500*000inhabi­
tants.Itsactivitiesaresatisfactory' althoughtheoccupancyrate
isonly63/j*Therearenearly50operationsand25childbirthsper
weekand300consultations perday.Asaresultofinsufficient
maintenance ,theexternalappearanceofthebuildingsleavessome­
thingtobedesired.
u)Cost:518.000u.a

1/6 VIIl/467{75)-E
(b)Thehospitalgrou?inSavalou
Thepurposeof.extendingthemedico-surgical centreinSavalouwasto
improvetheworkingconditionsofahealthunitwhichwasequippedwith
medico-surgical facilitiesbuthadlimitedhospitalization capacity
andinsufficient maternityfacilities#
Theproject(l)involvedtheconstructionofa30-bedmaternityunit
andamaternityandchildhealthcentre.Thecapacitywasthusincreased
to126"beds,whichcorrespondstotheneedsofthedistrictpopulation
of65*000,Withatotalstaffof40,led"byadoctor,thehospitalgroup
functionssatisfactorily .Themodestbutrobustandpracticalbuildings
arewell.maintainedandmakeagoodimpression.
(c)lîaternityunitinLolcosca
Theobjectiveinbuildingthismaternityunit,whichwasinitially
plannedforAthiemebutactuallybuiltinLokossa,wastomodernize
the.existinghealthunitsince.itsbuildingswereindisrepairandits
capacitywasinsufficient.
Th<?project(2)providedforthoconstructionofamodern36-bedmater­
nityunitandtheconversionoftheexistingmaternityunitintoa
hospitalpavilion.Theconstruction workwascompletedin1961,butthe
buildingswerenotinfactoccupieduntil1966,whentheywereconnected
..tothelocalwatersupplynetwork.
Thematernityunitisfunctioningexcellently andthebuildingsare
wellmaintained.
(1)Cost:85.OOOu.a.
(2)Cost;40.000u.a.
./■

1/7 Vlll/467(75)-E
3)Mauritania :NationalhospitalinNouakchott
InMauritania ,Communityaiduasfinancedtncconstruction ofthe
nationalhospitalandtheschoolofnursing,Fartherdecisionshavo
beentakenonthefinancing'oftwnadditionalprojects :in1973onthe
buildingofapolyclinicinNouakchottandthe
organization ofamaintenance department ,andin1974ontheextension
ofthenationalhospital.
Atthetimeofindependence ,whentheprojectfortheconstruction and
equipmentofahospitalandschoolfornursesinNouakchott wasbeing
studied,thesituationinMauritania wascharacterized by:
-uncertainty astothefutureofthenowcapitalinNouakchott ,
forwhichamaximumpopulationofonly15to20.000inhabi­
tantswasplanned;
thealmostcompletelackofancillarymedicalstaff;
-thelackofanyrealhealthinfrastructure -atnationallevel:
onlythreehospitalunits,withoutmajortechnicalresources,
wereoperatingwithintheterritory(l),togetherwithavery
snailnumber .ofmedicalcentresofminorimportance.Two-
thirdsoftheseriouslyillpatientshadtobetakentohospi­
talsinneighbouring countries,particularly toSt.Louis
andDakarinSénégalandKayesmMali.
Asaresult,theproject(2),whichwasdocidedonin1961,wasdesigned
toprovide s
-thefirst135-bedsectionofalargerhospitalwithaplanned
finalcapacityof250beds;
-thefirstpartofaschoolofnursingpartiallyintegrated
&intothehospitalfortherapidtrainingofmiddie-rank hospi­
talstaff;
-thefirstpartofafuturenationalhospitalwhichwouldservo
nationallyasacentrefordiagnosisandmoreseriouscasesand
locallyasahospitalcentrefortheregionaroundthecapital.
(1)Atar,Aioun,Kaedi
(2)Totalcost2.5millionu.a.

1/8 VIIl/467(75)-E
Thetoclinicaldesignhadto"besuchthatfutureextensionscouldbe
carriedoutwithoutmodifyingthetechnicalservicesandwithoutdistur­
bingthehospital'soperation.Consequently ,themedicalinstallations
wererelativelyover-generous forthenumberofbedsinstalled.Onthe
otherhand,itwasabletomeettheexistingnationalhealthrequirements
fromthestart.
Thearchitectural designofthehospitalasalarge,modernthree-level
complex,dominatingbyitspositionthewholetownofNouakchott'isan
undoubtedsuccess.However,thedesignwasboundtohaveaneffectonthe
hospital'soperation,andthetechnicaldesignofcertainitemsofequip­
menthasprovedtobetoocomplicatedforacountrysuchasMauritania,
Themaintenanceofthehospitalwasparticularlydifficultduetothe,
totallackofqualifiedstaffandtheproblemoftransporting spareparts
Irlgeneral,thehospital,whichcameintoservicein1966,hasfulfilled
itsobjective^well,andtheincreaseinitsactivitieshasbeendramatic
ThenumberofpatientshospitaliBed morethandoubledbetween1967and
1972*.Thenumberofoperationsdoubledbetween1969and1972andthe
occupancylevelreachedandeventemporarilyexceededthe100%mark.
Lastly,thenumberofoutpatients hasincreasedtosuchanextentasto
disturbtheproperfunctioningofthehospital'sservices.
Thehospital'scapacityveryquicklyprovedtobeinsufficient fortwo
mainreasons:
f-thetownofNouakchotthasdevelopedataratethatwasmver
,,expectedandhasreachedapopulationofbetween50and70,000;
-theimprovementofthetransportnetworkandmeans ■.
withinthecountryhasfacilitatedthemovementofpatientsto
thenationalhospital.
Toremedythissituationwithinthehospitalitself:
-thedefactocapacityhasgraduallybeenincreasedfrom135"t°
230beds(l)bytheadditionofbeds,atthesacrificeofthe
1
essentialspaceneededbyeachpatient;
(1)I974:250beds.

1/9 VIII/467(75)-E
-"theaverageperiodofhospitalization hassometimesboencut
downtothesafetylimit;
-adraconianselectionofadmissions hashadtobemade.
WithintheframeworkofpolicyofexpansionadoptedbytheGovernmentpro­
vidingfortheprogressiveestablishment ofahealthinfrastructure ontiro
levels,thefollowingprioritieshavebeenset:
-thepartialincreaseofthenationalhospital'scapacityby
relievingitofitsmostsimplecasesviathecreationofan
urbanpolyclinicinNouakchott ;
-theoverallextensionofthehospital'scapacity;
-themaintenance andimprovement ofallexistingmedico-techni­
calinstallations .
Inordertoattaintheseobjectives,,decisionsworeadoptedbytheCommunity
in1973and1974tofinance:
-theconstruction andequipmentofanoutpatients ,first-aid
andselectioncentreinthetownofNouakchott asthefirst
operational partofafuturepolyclinic ;
-thetechnicalassistanceofatrainingexpertforaperiodof
twoyearstoorganizethemaintenance departmentandthe
trainingofstaff;
-theextensionofthehospital .toafinalcapacityof450beds
bytheadditionofspecialistservicesnotyetinexistence
andtheenlargement ofothers;thiswillenablethehospital
trulytofulfilitsroleasthenationalhospital;
-theextensionoftheschoolfornursesbytheconstruction of
newteachingpremises.
Inviewoftheintenselevelofactivities,thepresentstaff(atotalof
approximately 200including11doctors)seemstobeoverworkedandthe
qualityoftreatmentcanonlybesufferingfromthis.Onthebasisofa
comparisonwithotherhospitalswithasimilarlevelofactivities,astaff
complementofbetween250and300wouldseemtobemoreadequate.
•/•

1/10 VIIl/467(75)-E
Theoperatingbudget(staffexcluded)availabletothehospitalhasnot
keptpacewiththedevelopment ofitsactivities ;itincreasedbyonly
10/5between1967and1972.However,itsfinancialresources(CPAP75*5
millionin1972)areatalmostthesamelevelasthebudgetsofthe
hospitalsinZinderinNigerandBoboDioulassoinUpper-Voltainspite
ofappreciabledifferencesinhospitalcapacity(l).Theoperatingcosts(2)
perbed(CFAF330.000)andperday'shospitalization (CPAP940)arevery
favourablecomparedwiththeothernationalhospitalsforwhichfigures
areavailable(3),hencetheconclusionthatthefundsallocatedtothe
Nouakchotthospitalcanbeconsideredamplysufficient.Accountshould
nevertheless betakenofthefactthattheheavyandspecialized medical
equipmentofthisnationalhospital,withalltherelatedinstallations
(twooperatingtheatres,radiologyblock,laboratory,pharmacy,etc.),
»■
whichwereinstalledasthefirstinstalmentofalargerhospital,
haveadisproportionate effectoncurrentexpenses..■
Inshort,theusemadeoftheEDFinvestmentinNouakchott showsthat
theplannedobjectiveshavebeenfullyachieved.Communityaidhas
suppliedthemostimportantbasicelementinthecountry'shealthinfra­
structureand,encouragedbythissuccess,theCommunityhascontinued
tocontributetowardsthissector.
(l),Nouakchott230beds(1974»250beds),Zinder450beds,
BoboDioulasso700beds.
(2)Basedon1972budgets.
(3)Mogadishu CPAPI85.OOOandCPAP565(1973)
Ouagadougou CFAF116.000andCPAF390(1973)
Niamey CFAF225.000andCFAP670(1975)

1/11 VIIl/467(75)-E
4)Somalia:GeneralhospitalinIlogadishu
Theinitialprojectfortheconstruction andequipmentofanew
generalhospitalinMogadishuwasfollowedbyanumberofconsecutive
technicalassistanceandtemporaryoperatingaidprojects.
Theobjectivesoftheinitialproject(l),whichwasdecidedonin
1959»involvedtheconstruction andequipmentofa600-oedgeneral
hospitalinMogadishuto:
-replacetheexistinggeneralhospital(DiMartina),whichwas
consideredtobebeyondrestoration ;
-modernizeandimprovethehospitalservicesinSomalia,and
particularly inMogadishu,tosatisfythegrowinghealthre­
quirements.
Thedesignoftheproject,whichwasdrawnupbeforeSomalia'sindepen­
dence,wasbasedonthreeessentialpremises:
-theformalundertaking (2)bytheTrusteeship Adminis­
trationtoobtainexternalaidintheformofmedicalstaff
•until1970a"tleast:
-thereplacementoftheoldDiMartinoHospitalandtransferof
itsstaffandfundstothenewhospital;
-theprovisionfromthehealthbudgetofadditionaloperating
funds.
In1962,afterindependence ,whenthohospitalwascompletedandpartly
equipped,itbecameapparentthattheSomaliGovernmentwasnotable;
-eithertoobtainenoughexternalaidintheformofmcdiiaj.staff,
Italyhavingprogressively reduceditstechnicalassistance ;
-ortofinancefromitsownbudgettheremuneration ofthe
doctors(whoofcoursewereforeignsincein1963Somaliahad
onlytwonationaldoctors)andofthenecessaryancillary
medicalstaff;
-ortopayfromitsownbudgetfortheoperationofthehospi­
tal.
./.
(l)Totalcost:2.8millionu»a.
(2)Specifiedinthefinancingagreement,whichwasBignedin1959before
independence .•

1/12 rai/467(75)-E
Furthermore ,theoldDiIlartinohospitalwasnotclosed,down.
In1964tconsequently twoyearsafter,itscompletion,thehospitalhad
stillnotcomeintooperation.FollowingarequestfromtheSomaliGovern­
ment,theCommunitytookthe.necessarymeasurestoensure,exceptionally
andforalimitedperiod,theentryintoserviceofthehospital.This
seriesoftsrnprrar.ytechnicalassistanceoperations(l),whichcombined ,
CommunityactionandcoordinatedbilateralactionbyMemberStates,amongwhich
Italy,beganin1964an(ltaperedoffprogressively.It.comprised:
-therecruitementof31doctors(1964-70);
-therecruitement ofJOancillarymedical,administrative
andtechnicalsupervisory-level staff(1965-70)»
-thepaymentofoperatingexpenditure (1966-72).
Infact,thehospitalasawholebegannormaloperationonlyatthebegin­
ningof1966. ■...
Aftertheopeningofthehospitalandtheassumptionofoperatingexpendi­
turebytheEDF,manymanagementandorganizational problemsarose.These
poisonedtheworkingatmosphereandcreatedagenerallackofbooperation ,
ofanyspiritofsolidarityandevenofrespectformedicalethics.They
alsocalledintoquestionthevalueoftheCommunity^technicalassistance.
Inaddition,thehospitalfounditselfinthethickofsomepolitical
rcompetitions :theoldDiMartinohospital,,insteadof .
beingclosed,wasimprovedandadministered notwithoutsuccesswith .
Sovietfinancialaid.Thereisnodoubtthatthissituationcreated,among
otherproblems,ageneraltendencytoallsortsofexaggeration tothe
pointwherethehospitalhadbecome,intheviewofEuropeansaswellas
theSomalipopulation,the"Mogadishudisaster",eventhoughinreality
theestablishment wasalreadyworkinginafairlysatisfactory way..
Inspiteofallthedifficulties whichthehospitalhasexperiencedfor
reasonsunconnectedwiththeCommunity,thehospitalhastodayattained
toagreatextenttheobjectivessetforit.Ithashelpedtosatisfythe
increasinghealthrequirements andhasprovedtobegenerallywellsuited
tothecapacitiesoftheStateintermsofqualifiedstaffandoperating
funds. /
(l)Totalcostofthe8projects:4*9millionu.a.financedbytheEDF.

1/13 VIII /4^7(75)–E
Thepresent level ofactivities -ofthe ^hospital shows that itsutility
andeffectiveness areundeniable *Theoccupancy rate forits600beds
was89 in1973 compared with 79chin1967# There are35operations
and 85childbirthe perweek andoutpatient work hasincreased dramatical­
lysince 1967 "toreach anaverage of500outpatient consultations por
woxkiag day#
Thehospital iscurrently being runonanormal basis bytheMinistry
ofHealth .Thestaff complement issufficient (420)ifnot abundant
compared with otlier major hospitals inAfrican capitals .Thereplacement
ofthemedical staff bySomali nationals iswell advanced ,andofthe
31doctors allocated tothehospital ,25arcSomali .Theprocess of
filling thoancillary medical ,administrative andtechnical posts by
Somali staff wascompleted in1970 *
Theoperating budget (staff excluded )canbeconsidered sufficient to
maintain anaverage level ofoperation ,andisquite comparable with
that ofother national hospitals .Itis,however ,below thelevel pro­
vided bytheCommunity during thotransitional period ,when itwas
meeting alltheoperating costs .
Themodem six-storey building ,which wasbuilt between I960 aJid1962 ,
isstill inagood condition owing toitstechnical design ,which is
well suited tothehotandhumid climate ,andtosatisfactory current
maintenance work .Ontheother hand ,some ofthefixed installations
have deteriorated -oreven become unusable .Thomedical equipment ,part
ofwhich hasbeen replaced andmodernized ,isinasatisfactory or
tolerable condition .Thehospital suffers from theeternal problem of
the shortage ofqualified maint fiance staff rather than ofavailable
funds .Asaresult ,aprogramme forthetraining ofmaintenance staff
forthehospital iscurrently bc:.ng studied bythe Commission .

1/14 VIIl/467(75)-E
5)HealthunitprojectsundcrtakeninUpperVolta
TheinvestmentprojectsfinancedinUpperVolta(l)fromtheresources
ofthefirstEDF,whichweredecidedonin1961,comprised:
-theconstruction andequipmentoftwosecondaryhospitalsinGaoua
(120beds)andFadaH'Gourma(2)(130beds);
10TypeA(21"beds)andType£(35beds)medicalcentres;
-theconstruction of14unitsforthemajorendemicdiseasesdepart­
ment; '
-themodernization oftheopthalmological dispensaryinOuagadougou,
BasedonageneralplanforthefuturetoprovideUpperVoltawithhospi­
talfacilities,theprojectswereintegratedintotheexisting,geogra­
phicallywell-established infrastructure soasto:
-buildup,modernizeandsupplementahierarchical andcoordinated -
hospitalsystemwithallthetreatmentunitsformingtheconsti­
tuentpartsofawe11-organizedandfunctionalwhole(3);
-improveworkingconditionsforthepurposeofcampaignsagainstthe'
majorendemicdiseases,inparticularleprosyandtrypanosomiasis .
Thegeneraldesignoftheprojectswasgovernedbyaprudentapproach
andprovidedfoytheimplementation ofthefirststageonlyofaplan
forthefutureinordertokeepwithinthecountry'sfinancialandstaff
capacitiesoverthenextfewyears:theprojectwasconfinedtotwo
outoftheplannedsixsecondaryhospitalsandtotenoutoftheplanned
18ruralhospitals,inaddition,theprojectcomprisedonly:
-thefirststageofthetwosecondaryhospitals,comprisingapproxi­
mately130hospitalbeds,outofthe230plannedforGaouaandthe
400plannedforPadaN'Goumia;
• ..
(l)Totalcost:4*4millionu.a,
.(2)TheinitialplantolocatethehospitalinKoudougouwaschangedin1966,
(3)ThetwogeneralhospitalsinOuagadougouandBoboDioulaspo-thetop
ofthe"hospitalpyramid"-andthesinglesecondaryhospitalinexistence
(Ouahigouya)hadalreadybeenenlarged,improvedandmodernizedin
1961/62withthehelpofFrefcohfinancialaid.

1/15 VI;I/467(75)-S
-tueintroduction ofruralhospitalstobeknownas"healthcentres";
inviewofthedesiredgradation,twodifferenttypesweredesigned:
•theTypeAhealthcentre(basicformulawith21beds)toberan
byamalenurse;
•theType3healthcentre(moresophisticated formulawith35beds)
toberunbyadoctor;
-fortheunitsofthemajorendemicdiseasesdepartment,thereplace­
mentoftheantiquatedunitsbuiltoftemporarymaterials.
Afeatureofthetechnicaldesignisthestandardization ofthestructure
ofthebuildingsbyusingaprefabricated system(exceptfortheunitsof
themajorendemicdiseasesdepartment)andofthetypesofbuildings.So
itispossible,UBingapavilionsystem,tocarryoutfuturestep-by-
stepextension withouthavingtoconvertthebuildingsandwithoutdis­
turbingtherunningoftheunit.Theprefabricated buildingshaveproved
tobefunctionalandwellsuitedtotherequirements ofthehealthdepart­
ments.Inspiteofthelackofregularmaintenance ,exceptinthetwosecon­
daryhospitals,thebuildingsaJ?einexcellentcondition.
Thepresentlevelofactivityoftheunitsthathavebeenbuiltappears
generallyspeakingtobesatisfact )ry.Althoughthehospitalcapacity
createdisnotalwaysfullyutilised,theestablishments carryoutaconsi­
derablelevelofexternalactivities.Theoccupancyrateofthetvjosecon­
daryhospitalsisbetween50ana6"'/»»outpatientconsultations number
approximately 400perworkingday.Forthehealthcentres,theaverage
occupancyrateis50withanaverageofapproximately 130Qutpationt
consultations perday.
Theunitsofthemajorendemicdi~/asesdepartmentintendedfortheisola­
tionofpatientssufferingfromIcorosyandtrypanosomiasis arenotall
beingfullyutilized.Withtheintroduction ofaneffectiveeuro,theold
methodsinvolvingtheisolationoflepershavebeenmadeunneces­
sary,andthecontagiousstageofleprosyhasbeenshortenedtoafewmonths.
Inaddition,trypanosomiasis isverymuchonthedecline.

1/16 VIIl/467(75)-E
ThestaffallocatedtothemedicalunitsfinancedbytheEDFissufficient
forthelevelofactivities# Thetwosecondaryhospitals,aftersomedelay
intheirentryintoserviceasaresultofthelackofdoctors,nowhave
foreignmedicalstaff(l);eachTypeAhealthcentreisrunbyamalenurse,
whoisanUpperVoltanational,andeachTypoBhealthcentrebyadoctor,
generallyforeign.
Onlyaverysraallpartofoperatingcostsofthehealthunitsisprovided
bythecountry'sownbudgetresources(MinistryofHealthandlocalauthori­
ties).Itisonlythankstotheadditionalfinancialandotheraidfromall
sources(bilateralandmultilateralaid.aidfromprivate,philanthropic ,
\.«. .. 'religiousorganizations ,etc.)thattheunitscanoperateinasatisfactory
way.Thegreaterpartofthebudgetsofthetwosecondaryhospitalsarepro­
videdbyGermanaidandbythe"UteresdesHommes"-organization.These
budgetscanbeconsideredamplysufficient,andtheoperatingcosts(staff
excluded)perbedandperday'shospitalization arearenhigherthanthose
ofthegeneralhospitalsinOuagadougou andBoboDioulasso.Thebudgetsof
thehealthcentres,on.*theatharhand,areinsufficient ,andthefunds
allocatedirregularly bytheMinistryofHealthandthelocalauthorities
coveronlya.partofthefinancialrequirements.Againonlythevarious
sourcesofadditionalaidenablethecentrestofunctionsatisfactorily .
ThehealthunitsfinancedbyCommunityaidhavetoagreatextentachieved
theobjectivesassignedtothem.Thesizeoftheseunitsissuitedtothe
availablestaff,butisoutofproportiontothecountry'sfinancialresour­
ces.Theoperatingbudget(staffexcluded)oftheMinistryofHealth
amountstoonly14%ofthetotalhealthbudgetandwouldnotitselfsuffice
fortheoperationofthetwogeneralhospitalsinOuagadougou andBoboDiou-
lasso.Thefundamental imbalancebetweenthefinancialrequirements ofthe
existinghealthunitsandthecountry'sownfinancialresourcesiscompen­
satedonlybymassiveandcontinuousexternalaid.Thedefactobalancethus
achievedis,however,extremelyfragile,andthesuspensionofaidfromone
ormoreexternalsourceswouldhavecatastrophic consequences ontheopera­
tionofthecountry'shealthservices.
(l)FinancedbyGermanaidinGaouaandby"Freresde'sHommes"(aFrench
.non-profitmaking,non-political andnon-denominational association)at
FadaN'Gouraa.

-1/17- Vlll/467(7>)-B
6)Health unit projects undertaken inNiger
Theprojects implemented inNiger (l)andfinanced from theresources
ofthe first andsecond EDFs comprised :
-themodernization andextension ofthehosoital inNiamey ;
S
-theextension ofthe nospxtr.1 inZmder ;
-therenovation andmodernization of5departmental hospital
centres (liaradi ,Dosso ,Tahoua ,Agados andDiffa );
-theestablishment of6hygiene andmobile medicine centres
(Zinder ,Maradi ,Dosso ,Tahoua ,Agades andDiffa );
-therenovation of3arrondissement hospital-dispensaries ;
-theconstruction of16rural dispensaries ;
-the construction ofastorage warehouse forthe supply pharmacy .
In1962 »"theNiger Government submitted totheEDFaninitial project
forthe construction ofanewhospital inNiamey .Anoverall study of
theproblems showed ,however ,that thehealth infrastructure situation
ofthecountry called foranumber ofextension andmodernization
projects inpreference .Theprojects were based onaplan forthe
future (2)andtheir main objectives were to :
-remedy thepoor quality oftheexisting hospital installations ,
particularly intherural centres ;
-improve further theoverall health infrastructure ,which comprised
abody ofhealth services well suited tothehealth requirements
andtotheparticular conditions ofthevarious regions ofthe
country .
Thegeneral design oftheproject fitted harmoniously into this overall
development plan forthepublic health services andwas inline with the
guiding principles which hadbeen adopted :priority fortherural areas ,
priority forthose projects which could increase theefficiency ofthe
services while involving theminimum additional recurrent expenditure ,
priority fortherenovation ofoldbuildings inastate ofdisrepair ,
(l)Total cost :%7million
(2)Prospects forthedevelopment ofthehealth services over theten-year
period 1965-74 adopted bytheNiger Government ,
/■

1/18 VIII/467(75)-E
theprincipleofbuildingnewunitsonlywhenthequalified ,staffwas
available.
AsinUpper-Volta ,afeatureoftheteclinicaldesignisstandardization of
thestructuresandofthetypesof"buildings,Alth6ughthesetechnical
characteristics wereparticularlysuitedtothenewbuildings(dispensaries,
hygieneandmobilemedicinecentres),theextensionworkcarriedoutfitted
inharmoniously withtheparticularlayoutoftheexistingunits#Thenew
buildings,whichcameinto^servicein1973ihaveprovedtobeveryfunc­
tional,andallthebuildingsandequipmentareinexcellentcondition.
Thelevelofactivitiesofthemodernized,improvedandenlargedmedical
unitsisgenerallyverysatisfactory.ThenationalhospitalsinNiameyand
Zinderarebeingfullyused(upto100%),Theusemadeofthedepartmental
hospitalcentresisalsoverygoodandwillincreasefurtherattheexpense
ofthehealthcentresasaresultoftheGovernment'sdecisionin1974to
gathertogetherallthedoctorsinthechieftownsofthedepartments.
However,theactivitiesofthehealthcentresandofthedispensaries are
alsosufficient.Thebuildingsofthehygieneandmobilemedicineteams
areingeneralwellusedjtheiroperationdependsessentially ontheinitia­
tivestakenbytheseniordoctorincharge.
Thenumberofstaffallocatedtothetreatmentunitsseemstobesufficient
andthestaffisingeneralwellqualified,butthenumberofstaffallo­
catedtothemobileteamsisinsufficient.
Theoperationofthehealthunitsisfinancedinafairlyregularfashion;
thehealthbudgetandthequotaofthefundsearmarkedforoperating
expenditure makeitpossibletoguaranteeafairlyhighleveloftreatment
servicesattheupperlevel(nationalhospitals,departmentalhospital
centres),whiletheoperationofthehealthcentresareaandoftherural
dispensariesisfinancedfromthefundsofthelocalauthorities.Thesole
exceptionisthatthemedicaments aredistributedinkindtoallthemedical
serviceswithinthedepartments.Thegreaterpartoftheoperatingexpendi­
ture'ofthetreatmentunitsisthusprovidedfromthecountry'sownbudget

1/19 VTII/467(75)-E
resources,whilethemobilemedicineprojects(prevention,detection)
areamplysupportedbyexternalfinancialandothera,id.Tosunup,the
country'sownbudgetresourcesarenotsufficienttoprovidemedical
treatmentwithfixedstructures andalsotoundertakesocialmedicine
projects;consequently ,themajorityoftheseownfinancialresources
areallocatedasamatterofprioritytothefixedtreatmentunits,
whilemostofthesocialmedicineprojectsarelefttoexternalaid.
fheutilityandeffectiveness oftheprojectscarriedoutinNigerare
undeniable.Theirharmoniousintegration intotheexistinginfrastructure
hasprovedtohaveparticularadvantages :theirgradualadjustment,in
quantityandquality,totheparticularandlocalhealthrequire-■,:>
mentshasentailedonlysuchadditionalcostsandstaffrequirements
ascaneasilybemobilizedfromthecountry'sownresources.Thisproject
constitutes asuccessfromallpointsofview.

1/20 VIII/467(75M
7)Health"unitprojectsundertakeninCameroon
ThefourprojectscarriedoutinCameroonandfinancedfromthe
resourcesofthefirstandsecondEDFsinvolvedtheconstruction and
equipmentof:
-eighthospitals,
-thirteenhospitalextensions(including3hospitalpavilions),
-"twenty-onebushdispensaries ,
-aschoolofnursinginBamenda,
-acentralsupplypharmacyinVictoria,
-accomodation fornineteendoctors.
Thevariousunitscameintoservicebetween1962and1971:"thehealth
unitsinnorthernCameroonmainlybetween1967and1969»andtheunits
insouthernEastCameroonandWestCameroonbetweenI969and1971*
Thetotalcostoftheseprojectsisoftheorderof8millionu.a.,that
isapproximately 20%oftheaidgrantedtoCameroonfromtheresources
ofthefirsttwoFunds. .•
Theobjectiveoftheseprojectswastobridgetheeconomicandparticu­
larlythesocialdevelopment gapbetweennorthandsouthandtoestablish
abetterbalancebetweenthenorthandthesouthofWestCameroon.
Inall,theseprojectsincreasedthecountrytshospitalcapacityby
1360bedsoutofthepresent15.750bedsinthepublichealthsector.
I11general,theprojectswer6integratedintoanexistinghealthinfra­
structureformingahierarchical ,coordinated systemofalltreatment
.units.Withtheexception ,ofthedispensaries ,theprojectswerelimited
totheextension,improvement andreplacementofexistinginstallations ,
therebyrestrictingthe.-increaseinrecurringexpendituretothemini­
mum. ; '*. '.
AH'thehealthunitsarebeingusedasintendedanditisclearthat
theyhavemadeadecisivecontributiontothequantitative andqualita­
tiveimprovementofmedicaltreatment,particularly intheruralareas.
Thefiguresshow,however,thatnotalloftheunitsareoperatingat

1/21 Vlll/467(75)-E
fullefficiency ;theirutilizationishampered ,aboveaJ4bytheshortage
ofmedicalstaffandoperatingfunds.
Anexaminationcarriedoutin1971°f'theusebeingmadeofthese
projectsshowedthattheshortageofdoctorsandancillarynodical
staffwasfairlypronouncedatthattine.Theproblemsnowsoeratobe
lessserious,however,ascanbeseenfromtheavailableoverallfigures
whichshowthefavourableratioofone'doctorto26.500inhabitants and
onenurseto3*100inhabitants.
ThefundsallocatedtothevarioushealthunitsfinancedinCameroonby
theEDFseemtobewellbelowthoseavailabletocomparableestablish­
mentsexaminedintheothercountries.Whatisthereasonforthis
unfavourable situation?Thehealthbudgetisrelativelyhigh
(CPAP3.952millionin1973/74),andinspiteofanunfavourablebreak­
downbetweenstaffexpenditure (74f>)andoperatingexpenditure (26%),
theoperatingbudgetofCFAF1*046millioniswellabovethebudgetsof
theothercountriesexamined.Thefiguresarealsocomparatively
favourable fortheannualpercapitaoperatingexpenditure.This,
however,isspreadoveralarger,morecumbersomehospitalinfrastructure
thanintheothercountriesexamined(atotalof15.750beds;onebed
per390inhabitants).Itwouldappear,consequently ,thatthehealth
infrastructure isoutofproportiontothecountry'sfinancialpossibili­
ties*Inotherwords,theinsufficient levelofoperatingfundsforthe
variousunitsseemstobeadirectconsequence ofthemaladjustment of
hospitalcapacity.
Generally©peaking,theprojectscarriedoutbytheEDFsufferedfroma
laGkofcurrentmaintenance workintheearlyyearsaftertheirentry
intoservice.Withtheparticularaimofremedyingtheshortageof
qualifiedmaintenancestaff,theEDFisfinancing-forafour-year
periodbeginningin1972-aprojectforthetrainingofhospital
maintenancestaff*Theobjectiveisto:

1/22 VXII/467(75)-E
-ensurethemaintenance andrepairofthemedicalequipment
installedinthecountry1svarioushospitalunits?
-trainonthejot)repairtechnicians groupedintomobile
maintenance and"breakdownteams;
-traingeneral-purpose workersinthehospitalcentres.
Afirstmobileteamisinoperationandiscarryingoutveryusefulwork,
visitingallthehospitalunitsinturn.

VIII/467(75)-E
Orig.F
Annex11/23
LISTofprojectstheutilization ofv:hichhas"beenexaminedrecently
Situationat30December1974
AccountmgNumiber Titleofpro.iect Costofpro.ject
(ia'OOOu.a.)
CAMEROON 11,22.201
11.22.202
11.22.204
211.002.04
DAIIOMEY 11.21.602
11.21.603
11.21.604
UPPERVOLTA11.21.706
MADAGASCAR 11.24.106
11.24,10°
11.24.110
I1AURITAITIA 11.21.203
NIGER 211^013.10
211.013.14
2100.461.13.12Construction ofahospital .
pavilioninMeiganga
Construction ofahospitalpavi­
lioninN'Tui
HealthunitsnorthernCameroon
HealthunitssouthernCameroon
HospitalgroupinSavalou
HospitalgroupinAthierne••
SecondaryhospitalinParakou :
Healthinfrastructure and
ecruiument
Hospitalpavilionforthe
Majungahospital
HospitalinManakara
HospitalinPortDauphin
HospitalinNouakchott
Healthequipmentprogramme
Construction of16rural
dispensaries
Healthequipmentfor16dis­
pensaries64
60
2.737
4.765(1)
85
40
518
4.401
382
437
483
2.499
3.296(1)
.352(1)
2.024
•A
(l)Totalamountofthecontracte.

fV-, 11/24 VIIl/467(75)-l
AnnexIl/24
SOMALIA 11.31.001 NewhospitalinMogadishu 2.820
*'"11.31«003TechnicalassistancefotMogadishu *
hospital 895
11*31*005..'Temporaryaidfor./theadministra­
tionofMogadishuhospital 350
212.016,17 .Temporaryaidfotf.theoperation
ofMogadishuhospital 1»328(1)
212.116.19 Surveyonthepossibilities of~
reducihgtheoperatingcostsof
Mogadishuhospital ._.
(technicalassistance) 4
212.016.29 Temporaryaidfortheoperation
ofMogadishugénéraihospital 357(l)
212.016.34 TemporaryaidforMogadishu
._>hospital ,- •;334(1)
213»816.03OperationofMogadishuhospital .653
216.016.09 Temporaryaidfortheoperation
ofMogadishuhospital 990
(1)Totalamountofthecontracta.