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3.16    DMOs would be trained at a rate of 20 per year. The objective is to train 80 doctors over the life of the project, in order to Staff each of 38 districts (29 CMAs and the 9 CHRs) with two DMOs. This would enable the Staff operations and referrals to be adequately supervised throughout the primary and secondary levels of the district system.

3.17    To improve medical standards at the CMA surgical units, the project would provide for the training of six to seven district physicians in emergency surgery every year for 5 years (total of 32 physicians). Surgery will cover cesareans, hernias, extra-uterine pregnancies, and appendectomies. In addition, 32 nurses will be trained in anesthesia practices over the life of the project. Training will take place at the surgical departments of the two national hospitals and will last for a six month period for each doctor. Follow-up supervision will be carried out by surgeons from the regional hospitals.

3.18    The MSASF has staffing norms for district level health facilities. The CSPS norm includes a four person health staff, as well as one laborer. The CMA norm calls for a 31 person staff, of which 19 are health personnel. The project supports a policy reform to achieve a morę equitable facility distribution of staff through the modification of staffing norms to take into account existing workioads and ensure a minimum of qualified health personnel at all facilities. In particular each CSPS would initially be staffed with three health personnel: a nurse, a health worker and an assistant mid-wife. CMA personnel would be trimmed from a total of 31 staff members to 23. It appears probable, based upon a public expenditure review for the health sector completed in 1992, that these revised norms could be largely met for existing facilities through redeployment of existing staff. Staff could then be added as utilization rates improve. As a condition for appraisal, the Govemment issued a decision (Dicision No. 93-304/SASF/SG) formalizing minimum staffing norms for each CSPS, CM, CMA, and DPS. The Govemmcut provided assurances during negotiations that the minimal staffing norms would apply to all newly upgraded CMAs and their constituent CSPS. Prior to negotiations, the first phase (a staffing census) of the preparation of the redeployment plan and implementation of the first stage ("mini-redeployment") of the plan involving intra-provincial transfers, were completed. During negotiations the Govemment also gave assurances that a national redeployment plan acceptable to IDA would be prepared by June 30, 1995, in conjunction with the hospital sector study, and that implementation of the plan, involving redeployment from urban to rural areas and/or new recruitment, would be completed by March 31, 1997.

3.19 Implementation. UNICEF will oversee training of the DMOs under this sub-component based upon an agreement between the Govemment and UNICEF to be signed as a condition of credit effectiyeness. Training of district physicians in emergency surgery would be undertaken by the University of Medicine in Ouagadougou. Preparation of the redeployment plan would be carried out by consultants hired by the Govemment under the FHP and its implementation would be undertaken by the DAAF.

(c) Decentralize the public health system (US$3.9 million)

3.20 Obiectives and Description To support decentralization, the Goverament seeks the creation of 53 "Health Districts" centered around CMAs, with an average population density of 180,000 each. District health authorities would support, plan, supervise and monitor primary health care activities through the CSPS at the community level. The Govemment has given each district and its constituent CSPS (approximately 15) autonomy in planning, financial management, and budgeting through a decree issued in January 1993 (para. 2.37). The decree provides for cost recovery from the sale of essential generic drugs, retention and utilization of revenues generated