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laboratory tests, and hospitalization. However, CSPS and other primary health facilities were not allowed to charge for services. And, although drugs have been recently distributed free tbroughout the entire health system, they have represented only a smali portion of total drug consumption throughout the country (para 2.15). Starting in 1984 all locally-generated funds were sent to the Treasury, which takes 25 % to be used as generał government revenue, and sends 75% to a special account, the Caisse Maladie, which is managed by th« MSASF. Current legislation provides that the provinces' share be held by the Caisse until the end of the year, at which time each provincial Directorate is notifted that the province bas a credit in its name at the Caisse Maladie. In practice, the MSASF distributes this year-end credit as it wishes, frequently retuming these revenues to the Ministry’s generał budget.

2.19 In 1991, in connection with the provision of foreign assistance to national hospitals, the Govemment adopted a policy calling for self-financing (excepting salaries) of regional and national hospitals. This has reduced the health revenues flowing to the Treasury and hence the portion flowing to the Caisse Maladie. This loss of revenue for the MSASF has reduced the Ministry's ability to redistribute resources firom the tertiary level to the primary and secondary levels. Thus, it has become imperative that primary and secondary health facilities also be allowed to retain revenues from fees and sal es of drugs for the purchase of drugs and medical supplies. In January 1993, legislation was approved allowing the peripheral health facilities (CMAs and CSPS), in principle, to retain the funds they collect.

2.20 In 1991, MSASF employed 5,861 Staff members, representing approximately 17% of the total civil service. Population per physician is about 38,900, while population per nurse and trained midwife/birth attendant is 4,528 and 22,700, respectively. These numbers indicate an adequate number of nurses, but a considerable shortage of doctors relative to WHO recommended minimum rates for the Sahelian countries of 1 per 10,000, and, for midwives, 1 per 5,000. The vast majority of health personnel is employed by the public sector. There is a great disparity in staffing availability between urban and rural areas, with nearly half of Ministry personnel being based in the two main cities of Ouagadougou and Bobo-Dioulasso. There is also a considerable disparity in Staff availability among provinces, with the greatest shortages occurring in the northem provinces which are generally poorer and have the highest rates of malnutrition and infectious diseases.

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2.21 A study entitled Qualitattve Hurvey of Utilization of Health Senńces, undertaken in May-June 1992 as part of the preparation of the proposed project, provides a rather dismal picture of the population's perception of public health facilities. There were six main weaknesses identified under this Survey: (a) underutilization of fonctioning health services; (b) health workers' negative attitudes; (c) closure of a significant number of health services due to stafF shortages; (d) lack of affordable drugs; (e) a poorly fonctioning referral system; and (f) deficient equipment and non-existent maintenance. Solutions are complex given the interdependence of these weaknesses.

2.22 Underutilization of Functioning Health Seryices. The utilization ratę of public health facilities is very Iow and generally decreasing, particularly in rural areas. Today, utilization of health facilities is estimated to be below 30% of foli capacity. Particularly worrisome are the Iow levels of pre-natal examinations and the unsatisfactory vaccination coverage of infants—39% and 23% respectively in 1991, This underutilization results firom a perception of poor ąuality of