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Printed in 1994 by WHO
printed in Switzerland
W r id 0 ,
(2-8SS
Table of contents
Preamble
5
Executive Summary
6
I.
II.
9
9
9
9
Macroeconomic Developments
1. Background
2. Recent economic developments: Domestic sector.
a. Production
(i) Aggregate production
(ii) Structure of production:
b. Income, wages, and employment
c. Prices
3. Recent economic developments: External sector
a. Overview of balance of payments
b. External debt
c. Exchange rate
4. Macroeconomic policies
a. The Government’s economic and financial reform programme
b. Structural adjustment program
c. Official development assistance
d. Administration and state of planning procedure
e. Public finance
9
10
12
12
13
13
13
14
14
14
16
16
16
17
The Health Sector
1. Population and Urbanization
2. Health Status and its Determinants
3. The Health Care System
a. Organization
b. Types of Services
c. Levels of Services
4. Health Financing
a. Central Government Health Expenditures
b. Local Government Health Expenditure
C. External Aid
d. Households
5. Sector Policy and Strategy
19
19
19
20
20
20
21
23
23
23
24
24
25
lll.lmplications of Macroeconomic Developments for the Health Sector 26
1. Effects on Nutrition Status and Health Outcome
26
2. Effects on Health Service Delivery
27
a. Central Government Health Expenditures
27
b. Household Expenditures and Cost-recovery
27
c. Resource Needs and Financing
28
IV.
Implications for Actions
29
V.
Acronyms and Abbreviations
30
VI.
References
31
3
GUINEA
MACROECONOMIC EVOLUTION & THE HEALTH SECTOR
VI. Map of Guinea
VII.
4
33
Annexes
Table 1 - Gross Domestic Product by Sector of Origin, 1986-88
35
Table 2 - Consumer Price Index, 1985-88
36
Table 3 - Balance of Payments, 1986-90
37
Table 4 - Official Development Assistance, 1984-87
38
Table 5 - Government Budget, 1986-90
39
Table 6 - Population, 1988-2000
40
Table 7 - Nutrition and Health Status
41
Table 8 - Access Indicators
42
Table 9 - Regional Distribution of Medical Personnel in 1988
43
Table 10 - Central Government Health Expenditure, 1985-90
44
Table 11 - Financing Plan, 1990-1992
45
Figure 1 - Organizational Chart of the Socio-Economic Development
Support Project
46
Figure 2 - Organizational Chart of the MSPP
47
Figure 3 - Organizational Chart of the Regional Administrative Structure 48
Preamble
The objective of this country report is to assess the availability of resources for the Guinean
health sector and todiscuss the impactof macroeconomic developments inGuinea on health
expenditure and the health status of the Guinean population. Although important, the focus
of this report is not on the resource needs of the health sector, as reported by the Government,
neither on the efficient allocation of resources within the health sector.
As basic data with respect to GDP, prices, and investment as well as health status indicators
are either completely lacking or of very poor quality, an assessment of recent economic
developments in Guinea and their impact on the health sector must be regarded as very
tentative.
5
GUINEA
MACROECONOMIC EVOLUTION & THE HEALTH SECTOR
Executive Summary
Guinea is reported to have a per capita income of USS 400 (1988), which lies above the
average per capita incomeof Sub-Sahara Africa of USS 320, and itsagricultural and mineral
resources make it to one of Africa’s more richly endowed countries. Social indicators,
however, indicate an extremely low level of living standard which is comparable to that of
the poorest countries in Sub-Saharan Africa: life expectancy is42 years, infant mortality is
about 146, the under five mortality rate is about 248, and only about 13 per cent of the
population is estimated to have access to local health care.
The present leaders in Guinea which came to power in Apri 11984 started the implementation
of a comprehensive economic and financial reform programme in late 1985. The reform
programme has been supported from its outset by the World Bank, the IMF and several
industrial countries. The principal objective of the reform programme was to improve the
structure of incentives, and efficiency in the Guinean economy. The main measures in the
first phase of the economic reform programme included the decontrol of prices (except the
prices for rice and petrol), the devaluation of the Guinean currency, the liberalization of
internal and external trade, and administrative reforms which centered on staff reduction,
improvements of the efficiency of the civil service and the privatization or liquidation of
public enterprises. The second phase of the reform programme which started late 1988
focused at strengthening the management of public finances through improved budgeting,
resource mobilization and expenditure control, and the design of compensatory measures
to improve the conditions of life of the poor.
The reform measures have yielded growth of per capita income of 1.6 per cent per annum
in the period 1987-1989. One of the key results of theeconom ic reform programme has been
a shift in relative prices in favor of the private sector, and the rural sector in particular, and
at the expense of the public sector. Accordingly, agricultural production especially the
production of coffee increased in recent years. Agricultural growth is projected to average
3.6 per cent per annum in the coming years. Domestic rice production increased as a result
of the discontinuation of the distribution of rice at highly subsidized prices and favorable
weather conditions.
The shift in relative prices brought about by the economic reform programme lends to raise
employment and purchasing power in the private sector, and particularly in the agricultural
sector, and to lower them in the public sector. The purchasing power of civil servants has
been estimated to have declined importantly although salaries have been adjusted over the
last years. Staff reduction in the civil service have been substantial. A reduction of about
13,000 staff has been planned for 1989 in ministries with the exception of the administrative
staff in the Ministries of Education and Health. Whereas in the period 1984-1986jobs have
been created, more recently a deterioration of the employment market has been reported.
In the second quarter of 1989 only 6 per cent of those seeking positions found employment
compared to a reported 24 per cent in the previous year. In the rural areas segments of the
population and regions without direct access to rising agricultural output will most likely
face losses in their purchasing power as their nominal income is fixed while prices rise.
In manufacturing and commerce, small-scale enterprises and services showed an important
increase in their activities. Commerce is the most important sector of theGuinean economy
in terms of its contribution to GDP (38 per cent). The average growth rate in the secondary
and tertiary sectors is projected to be about 4 per cent in the medium term.
The mining sector, which is almost completely separated from the other sectors of the
Guinean economy, is critical for Guinea’s economy as it contributes about 77 per cent of
exporteamings and about 60 per ccntof the Government’s fiscal receipts in the period 19861988.
6
EXECUTIVE SUMMARY
Other major developments in the Guinean economy have been: The inflation rate has been
reduced from about 70 per cent per annum in 1986 to about 28 per cent in 1989. Extemaqlly,
the current account deficit which reached a peak in 1988 with USS 210 million is projected
to reach USS 83.3 in 1990. External debt roughly doubled during theeighties from USS 1,143
million in 1980 to USS 2,176 million in 1989. Debt service payments were equivalent to 6
per cent of GDP or 14 per cent of exports in 1989. The debt service-export ratio was slighdy
lower than the average rate for Sub-Saharan Africa of 15 per cent. Official aid per capita
doubled from USS 21 in 1984 to USS 42 in 1988.
The Government budget deficit, which as share of GDP increased to 5 per cent in 1989, has
been almost exclusively externally financed in recent years. A main objective of the
Government’s budget policy in the early nineties will be to reduce the budget deficitas share
of GDP to about 3.5 per cent and to keep real expenditure roughly constant This budgetary
policy implies for public health expenditure that it can only expand in real terms when other
components of government expenditure are reduced, i.e. the share of health expenditure in
total expenditure is increased. As budget resources will be severely limited for the
foreseeable future, it will be essential to make more cost effective use of existing resources
in the health sector.
The effect of the economic reform programme on the nutrition and health status is likely
to vary between segments of the population and between regions. Increasing per capita
income can be in general expected for the private and rural sector. Therefore, the nutrition
status of people who receive their income from activities in these sectors will tend to stabilize
oreven improve. Adverse effects of the reform programme include: lay-offsofcivil servants
and public enterprise employees, and losses in purchasing power as a result of price increases
of primary food products, rents, water, electricity, and health services. The most vulnerable
groups in the urban areas are urban poor, unemployed civil servants, unemployed former
employees in public enterprises and unemployed graduates. In the rural area the nutrition
status and the health status of groups that suffer losses in their purchasing power must be
expected to be affected negatively by the economic developments.
Whether and to which degree the nutrition and health status of the most vulnerable groups
will be affected by the reform programme and the economic development will also depend
importantly on the efficacy of the Government’s social policy and the extent to which
unemployed will find employment in the private sector. The Government’s social policy
which has been part of the reform programme is specially designed to cushion the adverse
effects of the economic reform on vulnerable groups. One measure of the social policy
package are transitory severance payments for civil servants who are not reemployed in the
newly organized public administration. NGOs are considered to have a particularly
important role to play in meeting the immediate needs of vulnerables groups during the
adjustment period.
As the efficacy of the Government’s social policy programme is of key importance to the
health sector an adequate participation of the MSPP in the formulation, implementation and
monitoring of social policy measure should be ensured.
Public health expenditure increased in real terms on average by 24 per cent per annum
between 1986 and 1989. The trend of rising real health expenditure is likely to have been
broken in 1990. In this year budgeted health expenditure decreased in real terms even
assuming an inflation rate as low as 16 per cent. As real overall government spending, in
contrast, is projected to increase by about 7 per cent the share of health expenditure to GDP
will decrease. This Government policy appears to be in contradiction with its stated
objectives to give a high priority to social expenditures including health expenditure. Given
also the relatively low share ofcurrenthealth expenditure incurrentgovemment expenditures,
discussions are needed about the reallocation of funds from other sectors, such as defense,
to health. However, even if a larger share would be attributed to health, government health
expenditure per capita will remain modest in the coming years. Thus, it is imperative that
7
GUINEA
MACROECONOMIC EVOLUTION & THE HEALTH SECTOR
resources arc used as efficiently as possible. The proper mix of inputs financed by the health
budget needs also to be examined. Capital health expenditure is to about 90 per cent
externally financed and therefore relatively independent from government revenues.
In its national plan the Guinean health ministry (MSPP) proposes a programme whose
overall cost amounts to USS 76.2 million for the period 1990-92. About 10.8 per cent of the
expenditures are planned to be financed domestically , and 10.9 per cent externally.
Financing for about 78 per cent of the costs still needs to be found. As there is no guarantee
that the Central Government will be forthcoming with the necessary funds and a substantial
financial gap exists for which financing has still to be sought a realistic reassessment of the
plan may be required.
8
I. Macroeconomic Developments
1. Background
During the presidency of Sekou Toure (1958-84) Guinea’s private sector was largely
replaced by a network of state enterprises and controls in all sectors of the economy. Guinea,
having been a major exporter of agricultural products at independence (1958), was
transformed by the mid-seventies into an important bauxite exporter and a net food importer.
The separation of the economy in an official and non-ofTicial sector became increasingly
important. While the official sector depended on the exports of minerals for its income and
functioned through a system of administered prices the non-official sector derived its
income from clandestine exports and private transfers from abroad and was supplied largely
by smuggled imports. At the beginning of the eighties, the non-official sector satisfied
almost all demand for marketed consumer goods in rural areas and about 80 per cent of urban
consumer demand.
Severe financial difficulties in the early eighties indicated a serious deterioration of
Guinea’s economy. Its external position was characterized by mounting debt service
obligations, private capital flights and a massive accumulation of payments arrears which
amounted to over USS 300 million at the end of 1985. The exchange rate was seriously
overvalued with an official rate of 23 Sylis per U.S. dollar compared to 400 Sylis on the
parallel market. Domestically, the budget deficit expanded mainly as a result of declining
tax receipts and rising subsidies to public enterprises.
In April 1984 a new regime came to power by a military coup and Colonel Lansana Conte
was named President. The new Government designed an economic and financial reform
programme whose main objective has been to put in place a policy framework supporting
a market-oriented economic system.1 The implementation of the economic reform started
in late 1985 and since then the economic development in Guinea has been primarily
determined by these reforms efforts. The economic reform was from the outset supported
by a first Structural Adjustment Credit, two consecutive IMF standby arrangements and a
first annual arrangement under the Structural Adjustment Facility. The second phase of the
structural adjustment programme started in the second half of 1988.
One of the major results of the reform programme has been a shift in relative prices in favor
of the private sector and in particular agricultural production at the expense of the public
sector.
2. Recent economic developments: Domestic sector.
a. Production
(i) Aggregate production
Guinea, with a per capita GNP of USS 400 in 1988 according to the official statistics, would
be one of the richer countries of the least developed countries. However, given the poor
quality of the national accounts it may be questioned whether Guinea’s per capita GNP lies
significantly above theaverage percapita incomeofSub-Saharan Africa (USS 320). In terms
of natural resources Guinea is richly endowed with agricultural, mineral, and energy
resources.
1 For details on the economic and financial reform programme see section 1.3.
9
GUINEA
MACROECONOMIC EVOLUTION & THE HEALTH SECTOR
Throughout the 1958-1984 period, economic growth remained below the growth rate of the
population of slightly less than 3 per cent per annum. An exception was the period 197376 when expanding bauxite operations led to an economic expansion.
In the reform period 1987-89 the economy grew by about4.4 per cent per annum inreal terms
which represents an increase of about 1.6 per cent of per capita income.
Intheyearstill 1993 theGuincan economy is expected to grow by about4 per ccntper annum
according to recent estimates of the Ministry of Planning, the IMF and the World Bank.
Under the assumption that the population grows by 2.8 per cent this would represent an
average increase of per capita income by 1.2 per cent per annum.
(ii) Structure of production:
Agriculture, livestock, manufacturing and commerce, water and energy, and transportation.
The three principal sectors of the economy contributed roughly equally to the gross domestic
product in 1986-87. The most important activities arc services (38.4 per cent of GDP)
followed by industry (31.6 percent of GDP) and agriculture (30 per cent of GDP). Output
in the primary sector is estimated to have provided a livelihood for some 80 per cent of
Guinea’s population in 1980.
Agriculture
Agricultural production comprises mainly food crops (rice, maize, and cassava) and
bananas, pineapples, palm oil and coffee.
According to FAO estimates average food production per head was in 1985-87 about 5 per
cent lower than in 1974-76 and this despite the country’s substantial agricultural potential.2
The exports of agricultural products which accounted for 60 per cent of export in 1958
practically stopped following independence. Guinea having been a net exporter of food
grains at independence is now a net importer of cereals. In 1986, Guinea imported 100,000
tons of cereals, 30 per cent of which was provided by donor food aid.
In recent years agricultural production increased as relative prices shifted in favor of
agricultural production due to the economic reforms. Domestic rice production increased
due to favorable weather conditions and because prices rose strongly as a result of price
liberalization3. Similarly, coffee production and exports rose significantly in past years as
producer prices rose. Since the state coffee company has been replaced by private enterprises
producers have received as much as 80 per cent of the Conakry fob price for their coffee.
Currently, the diversification of agricultural production is emphasized to strengthen food
self-sufficiency by developing food crops and because cash crops facea difficult international
market. Given the pursuitoftheeconomicreformagriculturalgrowthisprojectedtoaverage
3.6 per cent per annum over the period till 1993.
Livestock and Fishing
The importance of livestock decreased drastically over the last fifteen years. Livestock
accounted for only 4 per cent of Guinea’s total output in 1987 compared to about 11 per cent
in 1973.
ThreequartersofGuinea’slivestock population is located in MiddleandUpperGuinea. The
population consists mainly of N’Dama cattle, sheep, goats and pigs.
2 Asofficial figures forcropproductionarenotavailableestimatescomputed by international
organizations arc the only source for data.
3 The official rice price functions only as reference price.
10
(.MACROECONOMIC DEVELOPMENTS
The fishing industry is in an early stage of development contributing only 0.1 per cent to
Guinea’s gross domestic product in 1987. As Guinea’s maritime resources are plentiful
fishing could contribute to Guinea’s food self-sufficiency and its trade account. In recent
years projects have started to exploit Guinea’s maritime and onshore potentials.
Mining
Since thecarly seventies when mining accounted for only about 3 percent of national output
mining became an important source of income contributing 21.1 per cent to GDP in 1987.
Presently, theextemal account and govemmentrevenue is largely dependent on mining. The
mining sector contributed about 77 per cent of export earnings and about 60 per cent of the
Government’s fiscal receipts in the period 1986-88. This dependence makes the Guinean
economy highly vulnerable to adverse trends in international bauxite and alumina markets.
Whereas government income is highly dependent on the mining sector only about 7,000
people are employed in the mining industry. The mining sector functions very much as an
enclave in Guinea’s economy.
Mining consists of the production of bauxite, alumina and diamond. Since 1979 volume
output has stagnated with the exception of the diamond production which rose sharply as
a new mining company entered production.
Manufacturing and Commerce
Manufacturing contributes only about 5 per cent of total value added in 1987. Plants are set
up for processing agricultural products and producing low value products for the domestic
markets. Commercial activities constitute the largest subsector of the economy before
industry and agriculture.
As part of the Government’s reform programme state enterprises have been privatized or
reorganized. Thirty-one public enterprises have been privatized since the beginning of 1986
and an additional seventy are in various stages of liquidation. Small-scale enterprises and
services arc showing an important increase in their activities, reflecting the shift in the terms
of trade away from the public sector towards the rural and private industry and service
sectors. The main activities are construction, agro industry, transport and trade. Further
privatization of enterprises and commercial activities is expected to stimulate growth in the
secondary and tertiary sector to an average rate of about 4 per cent per annum over the period
till 1993.
Water and energy
Guinea has one of the least developed urban water supply networks in West Africa, with only
nine urban centers out of 35 equipped with pipe systems. The majority of the urban
population of about 1.5 million, of which 0.7 million live in the capital city of Conakry, have
to rely on unsafe sources for their water needs, while only a minority has access to piped
water. In the rural areas, water supply is a quantitative problem in the north of Middle and
Upper Guinea, and a qualitative problem throughout the country where many villages do
not have potable drinking water.
In recent years several water supply projects have been started which include a major
expansion of the water supply network in Conakry and a reorganization of the water supply
sector and of its finances.
Transportation
The transport infrastructure is considered by the World Bank to be the single most severe
impediment to output recovery. In order to restore links between the capital and the interior
the transport system has to be improved considerably.
11
GUINEA
MACROECONOMIC EVOLUTION & THE HEALTH SECTOR
Projects to improve the road system which arc financed by the World Bank and by other
sources have started.
b. Income, wages, and employment
A main characteristics of the structural adjustment programme (SAP) has been a shift in
relative prices in favor of the rural and service sector and private industry, at the expense
of the public sector. The result has been a reduction in the number of civil servants and the
creation of jobs in the private sector. At the same time, the purchasing power in the private
sector in general and in the rural sector in particular has improved whereas some segments
of the urban population, in particular civil servants have suffered a decline in their
purchasing power. According to estimates purchasing power of civil servants has gone done
by 16 per cent in the period 1984-87.
The average monthly salaries of a civil servant was less than USS 50 (GF 20250) per month
in 1985 using the parallel market exchange rate for conversion. By comparison, in Mali,
whose per capita GDP is of the same order of magnitude as Guinea’s, civil servants cam
about three times as much. The official salary is considered to have represented only about
one quarter of total income, with the remainder coming from second jobs or other sources
of income. Although salaries have been adjusted over the past years to take account of price
rises in the basic commodities, civil servants’ real income is estimated to have declined
substantially mainly due to the loss resulting from the elimination of the distribution of rice
and other commodities to civil servants at highly subsidized prices. In 1986, more than 40
percent of the households in Conakry had expenditure levels below the basket of basic goods
which has been evaluated by the MPCI to cost GF 68,500.
By the end of 1988 public sector employees on active duty had been reduced by about
15,000, or 17 per cent. Transitional arrangements are in place to facilitate their absorption
into the private sector. A reduction of about 13,000 staff has been planned for 1989 from
all ministries except the administrative staff of the Ministries of Education and Health and
the custom and security service.
In the period 1984 to 1986 about 21,000jobs have been created in the small enterprise sector
in Conakry alone according to a survey undertaken by the Ministry of Plan and International
Cooperation. According to statement made by the President of Guinea in his recent
independence day address has the employment market recently deteriorated. In the second
quarter of 1989 only 6 per cent of those seeking jobs found employment compared with a
claimed 24 per cent in the previous year.
In orderto mitigate theadverseimpactoftheeconomic reform programmeon the vulnerable
groups, the Government has adopted a social policy programme details of wh ich are reported
in section 1.4.
c. Prices
Prices with the exception of prices for rice, petroleum products, public transportation, and
public utilities have been deregulated since 1985. The official price of rice and petroleum
products was raised to pass the effects of devaluation through to domestic prices. Measures
were also undertaken in 1989 to ensure that food aid rice is sold at full cosl
Inflation which has been a serious problem in Guinea appears to have been under better
control in recent years. The inflation rate in Conakry which peaked at 72 per cent in 1986
was reduced to 28.2 per cent in 1989 which was about 3 per cent above the target rate. Food
prices rose by about 38 per cent on average per annum in recent years. Food prices are
importantly determined by the depreciation of the Guinean franc as Guinea is a net importer
of food.
12
I.MACROECONOMIC DEVELOPMENTS
One of the highest price increases can be found for health services. In 1986 inflation in the
health sector amounted to 131 per cent which in the following year decreased to 45 percent
Pricesofhousing and electricity increased by even more than that of heal th services in 1986.
The inflation rate in Conakry of this subcomponent of the general price index was 233 per
cent in 1986.
3. Recent economic developments: External sector
a. Overview of balance of payments4
The structure of Guinea’s current account has been characterized by a trade account surplus
that was outweighed by a service account leading to an overall current account deficit The
current account deficit increased strongly in the eighties from USS 7.5 million in 1983 to
USS 210.3 million in 1988 which represented 18.3 per cent of GDP. In 1989, the deficit was
reduced to USS 125.5 million or 7.7 per cent of GDP (Table 3).
The substantial increase in the current account deficit is explained by a decreasing trade
account surplus and an rising deficit in the services and private transfer account The trade
account surplus decreased due to stagnating exports of bauxite and alumina which represent
80 per cent of all recorded exports, and expanding imports. The increase in the deficit on
the services and private transfers account has been due mainly to increased interest payments
on external debt and increased payments for services and transfers related to the public
investment programme (PIP). These unfavorable external payments performance resulted
in an accumulation of arrears on external debt and a depletion of foreign reserves in 1988.
In the first half of the nineties Guinea is expected to face a difficult external environment
with high current account deficits and resulting external financing problems. The projected
current account deficits are the result of deteriorating mining earnings after 1990, together
with the growth in private sector and public investment-related imports and scheduled
interest payments on public debt. To bridge the expected financing gap a combination of
resources of the third-year arrangement under SAF, debt relief, balance of payment
assistance including an enhanced SAF program, IDA adjustment lending and additional
SPA financing arc required.
b. External debt
Guinea’s total stock of debt roughly doubled from USS 1,143 million in 1980 to USS 2,176
million in 1989 which is equivalent to 134 per cent of GDP. About 64 per cent of Guinea’s
external debt was contracted on concessional terms in 1989 compared to about 59 per cent
in 1980. The share of multilateral debt in total long-term debt was 28.6 percent in 1989 and
that of official bilateral debt was close to 66.7 per cent. The remainder of the debt was
supplied by private creditors.
Debt service payments on long-term debt amounted to USS 98 million in 1989 which is
equivalent to 6 per cent of GDP or 13.6 per cent of exports. The debt service-export ratio
is slighdy below the average rate for Sub-Saharan Africa of 15 per cent in 1989.
During recent years Guinea took a series of steps to reschedule or refinance its external debt.
With the official creditors presented in the Paris Club several agreements were reached in
the period April 1986 to April 1989. As a result of the rescheduling actual debt service
payments were substantially below the scheduled level.
4 As with most of Guinea’s statistics the balance of payments data is rudimentary.
Smuggling has been widely spread and according to some estimates exports smuggled
amounted to up to USS 100 million per year.
13
GUINEA
MACROECONOMIC EVOLUTION & THE HEALTH SECTOR
Several industrialized countries wrote off recently parts of Guinea’s external debt. In
November 1989 USS 33 million of Guinea’s public debt to West Germany was written off.
Similarly, France announced that it had decided to write off debts of USS 259 million. In
December the USA wrote off an amount of approximately USS 5.4 million.
c. Exchange rate
The currency of Guinea is the Guinean Franc (GF). As part of the reform programme
launched in January 1986 the Guinean franc replaced the Guinean syli and in several steps
a flexible exchange rate system was introduced. Guinea maintains now a flexible exchange
rate system under which the exchange rate against the U.S.dollar is set in weekly auctions.
Apart from the official exchange market a parallel currency market still exists on a
significant scale due to the existence of distortions in the economy and de facto restrictions
in the exchange and trade system.
At introduction in January 1986, the GF was changed from GF 24.3 per U.S. dollar to 300
GF per U.S. dollar. Since than the Guinean france has devalued gradually. At October 1,
1990 the GF was quoted with GF 680 per U.S. dollar.
4. Macroeconomic policies
a. The Government’s economic and financial reform program5
The prime objective of the first phase of the reform programme wh ich started late 1985 was
to put in place a policy framework supporting a market-oriented economic system. Specific
measures that were undertaken included corrections of the seriously overvalued currency,
theestablishment of a new banking system, decontrol of prices, liberalization of internal and
external trade, improvement of the efficiency of the public sector by cutting employment
levels and by withdrawing from commercial and industrial activity and the reorientation of
public investment towards directly productive sectors.
In thecourse of 1986-87 progress was made towards implementing these measures. The new
Guinean franc (GF) was introduced in January 1986, replacing the syli as Guinea’s currency.
All prices were decontrolled with the exception of prices for rice and petroleum products.
Of the 128 state enterprises in existence in 1984,69 had been liquidated by mid 1988,20
had been transferred to private ownership, another 20 were in the process of privatization
or liquidation, and only 19 were to be retained as public enterprises. Administrative reforms
centered on staff reduction, improvement of the efficiency of the civil service and
decentralization.
Measures during the second phase of the reform programme which started in late 1988
focused at strengthening the management of public finances through improved budgeting,
resource mobilization and expenditure control, improving the legal and institutional
framework to enhance efficient resource allocation, establishing complementary measure
in support of growth, and the design of compensatory measures to improve the conditions
of life of the poor, concentrating on the most vulnerable groups and those directly affected
by the transitional costs of adjustmenL
Whereas the reform process slowed down in the first three quarters of 1988 it regained
momentum in the last quarter of 1988 and the first quarter of 1989. New organizational
frameworks for key ministries were adopted, progress was made in the selection of civil
servants to be retained, the liquidation of the national petroleum distribution company and
5 The reform programme is presented in the ‘Declaration of the Government of Guinea’s
Development Policy’, Annex V, World Bank (1988)
14
I.MACROECONOMIC
DEVELOPMENTS
its replacement by private operators was started, the structure of interest rates was revised
including the deregulation of short-term lending rates, food aid rice was sold at full cost, the
1989 budget was adopted more timeously, electricity tariffs were increased by 100 percent
and the petroleum pump price was raised by about 50 per cent.
These improvements in performance made possible the approval of a second annual
arrangement under the IMF’s Structural Adjustment Facility, SAL II being declared
effective on March 2,1989, and the conclusion of a Paris Club rescheduling on favorable
terms in April 1989.
An important component of Government policy are measures to cushion the adverse effects
of adjustment on vulnerable groups. During the first phase of the adjustment programme
transitional measures were concentrated on assistance to public employees who have left
or will leave their government or state enterprise jobs as part of the adjustment process.
Measures included compensating civil servants for the increase in the cost of living,
continued payment on a temporary basis of salaries to laid-off civil servants, voluntary
departure bonuses with access to loans at favorable rates for civil servants with bankable
projects.
During the second phase* the emphasis of the social policy component will be on transitory
measures to protect vulnerable groups and the development of a comprehensive social
policy reform concerned with increasing the participation of the poor in the growth process.
The specific measures include the maintenance of a safety net to protect vulnerable groups
against expenditure cuts, particularly in the health and education sectors, the continuation
of severance packages to civil servants leaving the public administration, the implementation
of a comprehensive social policy to upgrade the living conditions of poor and disadvantaged
groups, and the improvement of the Government’s capacity to monitor living standards of'
the population during the adjustment process. As part of the second phase the Government
also created a National Commission on Social Policy (CNPS) at ministerial level (Figure
1). The Commission is designed to supervise the development of social policy to be
implemented during the second phase. The CNPS and its official-level sub-committee
replaces the National Poverty Task Force (NPTF).7 The senior socio-economic adviser to
the Minister of Planning and International Cooperation will also be the Secretary of the
CNPS, and Chairman of the official level subcommittee supporting the CNPS.
As a complement to the growth-promoting objectives of the Structural Adjustment
Programme a Socio-economic Development Support Project (SEDSP) of SDR 6.9 million
has been designed.’ The mai n objectives of the project are to support actions for improving
access to employment and basic services for particularly vulnerable groups including those
adversely affected by the structural adjustment programme and to enable the Government
‘ The social policy component of the structural adjustment programme is outlined in the
‘Declaration of the Government of Guinea’s Development Policy’ reproduced in Annex
V of World Bank (1988).
7 The NPTF was established in September 1987, in the Ministry of Planning and International
Cooperation (MPCI), with special assistance from the representatives of UNICEF in
Conakry. It was composed of representatives of the departments concerned with planning,
finance, housing, heal th, social affairs, rural developments, transport and decentralization,
as well as representatives of international organizations such as World Bank, UNDP, and
UNICEF. The NPTF completed a report, entitled “Composante Social du Deuxiime Prct
d’Adjustcment Structure!, Rapport du Group de Travail Interminist€riel”, on the poverty
profile of Guinea, the identification of vulnerable groups in rural and urban sectors, the
identification of a first series of projects in the areas of basic education, primary health
care, nutrition, employment generation.
’ Sec the World Bank (1989a). Figures 1 shows how the project is institutional integrated
into the MPCI.
15
GUINEA
MACROECONOMIC EVOLUTION & THE HEALTH SECTOR
to develop a long-term programme for alleviating poverty in Guinea. The core of the project
consists of three main components: social policy planning, monitoring living standards
which includes the implementation of permanent household surveys to track the evolution
of living conditions of households during the adjustment period, and the establishment of
a pilot programme of sub-projects for socio-economic developmenL The aim of the pilot
programme is to channel funds to small, grass roots sub-projects assisting vulnerable groups
in the low-income segment of the population.
An example of a sub-project in the health sector that could be financed by the pilot
programme is a project initiated by Mcdccins Sans Fronticre (MSF) in 1986 to rehabilitate
health services in the area of Kouroussa, in Upper Guinea.
b. Structural adjustment program
The economic reform programme has been supported by loans from the IMF and the World
Bank. The first phase of the programme (1985-1988) was supported by an IMF Stand-by
Arrangement of SDR 33 million, by an IDA structural adjustment credit and a Special
Facility for Africa of SDR 38.5 million. In addition extensive Special Joint Financing from
Germany and Japan, and cofinancing from Switzerland, France and the United States, and
the IDA-financcd Technical Assistance Project for Economic Management (SDR 9.7
million) was provided.
The second phase of the adjustment programme (1988-93) has been supported by a second
IDA Structural Adjustment Credit of SDR 47 million, with additional financing from
France, the European Community, the African Development Bank, Japan and the United
States. The second phase will also be supported by a Second Economic Management Credit
of SDR 11.3 million with cofinancing from several other donors.
c. Official development assistance
Official development assistance to Guinea increased from USS 123.2 million in 1984 to
USS 278.1 million in 1988. Aid per capita increased from USS 20.8 to USS 41.9.
The main bilateral donors have been France .which supplied in 1988 alone about 31 percent
of aid, Italy and Japan. The main multilateral donors have been the IDA, UNDP, and the
EEC.
d. Administration and state of planning procedure
Public Administration
The public administration has been judged overstaffed and unproductive. Government
operations have been mainly handicapped by problems associated with an underpaid,
underemployed, and less-than-adequately motivated civil service. A major priority of the
economic reform has therefore been to implement administrative reform measures to
rationalize and decentralize public administration.
To improve the efficiency of the public service the Government has implemented measures
to cut the number of civil servants, to upgrade qualifications, to introduce a more adequate
rate of remuneration and to withdraw from commercial and industrial activities. Specific
measures are qualification tests for the personnel of all ministries. When the tests and
evaluations are completed new organizational structures as well as salary adjustments
conform ing to a new salary scale are to be implemented progressively. The new organizational
structure was planned to be completed in March 1988. Employees who fail to qualify for
the newly organized civil service will receive a severance pay to the equivalent of 6 month
of salary. Employees that choose departure from the civil service instead of participating
in the qualification tests receive a resignation premia. In this way the civil service of the
16
I.MACROECONOMIC DEVELOPMENTS
Central Government is planned to be reduced to about 45,000 employees compared to
60,000 employees at the outset of the program.
An important objective of the Government’s reform policy has been the decentralization of
public administration meaning that local branches of government and community
organizations take increasing responsibility forthedevelopment initiatives in their immediate
community. Within this process the Government encourages the entry of international,
community-oriented NGOs and the devclopmentof national organizations of the same type.
The NGOs are considered to have a particularly important role to play within the framework
of the Government’s social policy in meeting the needs of vulnerable groups during the
adjustment process. The international donor community has given special support to the
work of NGOs to ensure that the development projects that they finance are reaching the
most vulnerable groups of the population. Responsibility for supporting the decentralization
process and the participation of NGO’sis entrusted toaSccretariatofStatefor Decentralization
(SED).*
For improving the management of public finances particular emphasis is given to the
establishment of a comprehensive annual investment budget, which includes all foreignfinanced projects, so as to impose budgetary discipline and to take account of associated
recurrent expenditures. More specifically the Government will ensure that ministries are
notified about their expenditure ceilings, a monthly ceiling is placed on operating
expenditure commitments, directors of administration and financial affairs (DAAF) are
appointed in ministries, and a permanent mechanism is established for monitoring and
controlling staff levels and the wage bill on the basis of the census of civil servants.
The Government has also approved the second economic management support programme
(PAGEN II) in agreement with IDA and other donors. This project provides resident
technical assistants and short-term consultancy services to help the principal ministries to
improve their management of public finances.
To improve the coordination of economic policy the Economic and Financial Coordination
Committee (EFCC) has created a technical support unit. This unit is responsible for
systematically monitoring the economy and the recovery program.
Public investment programming
The Government adopted its first three-year rolling Public Investment Programme totaling
USS 592 million for the period 1987-89 in March 1987. The main share of investment (45
per cent) was directed towards rebuilding the country’s infrastructure such as transport,
telecommunication, and energy. Other important shares of public investment resources
were devoted to rural development (25 per cent), education (6.7 per cent) and health (6.2
per cent).
For the period 1989-93 the external financing requirements for the PIP are projected to total
USS 1,290 million. The Government is expected to fund an additional USS 283 million or
18 per cent
e. Public finance
The Central Government budget has been characterized by a rising overall deficit in recent
years from GF 12.1 billion (1.8 per cent of GDP) in 1985 to an estimated GF 85.2 billion
(5.2 per cent of GDP) in 1989. This development has been the result of increasing
expenditures while revenues stagnated in some years. A principle objective of the
Government is to reduce the budget deficit to reach a share of GDP per annum between 3.0
’ The resident missions of UNICEF and the World Bank have compiled a directory of NGOs
working in Guinea.
17
GUINEA
MACROECONOMIC EVOLUTION & THE HEALTH SECTOR
and 3.5 per cent in the period 1989-1992. The budget deficits in recent years have been
almost exclusively externally financed. In 1989, about 80.7 per cent of the deficit on cash
basis was foreign financed.
Total expenditure increased more than tenfold since 1985 and amounted to GF 322.9 billion
in 1989. The share of capital expenditure in total expenditure rose substantially from 6.5 per
cent in 1985 to 51.4 per cent in 1989. Most of capital expenditure has been foreign financed.
The rise in current expenditure, from GF 85.2 billion in 1986 to GF 156.8 billion in 1989
was mainly the result of rising wages and salaries, increases in defence spending which
accounted for a significant part of the increase in the goods and service subcomponent, and
growing debt servicing.
Total expenditure is projected to increase in the medium term in accordance with the
inflation rate implying constant expenditures in real terms. The composition of total
expenditures is planned to change. The trend of a growing share of capital expenditure is
projected to continue. Salaries are one subcomponent of cunent expenditure which arc
expected to grow even in real terms.
Total revenues including grants almost tripled since 1986 and amounted to GF236.8 billion
or 14.6 per cent of GDP in 1989. The tax base is rather narrow and highly dependent on tax
revenues from the mining sector which accounted for 68 per cent of total tax revenues in
1989.
Real revenues are expected to grow in the coming years. This increase is thought to be
brought about by a more efficient tax collection in other sectors than the mining sector in
which the tax collection is already tightly controlled. Whether the planned cuts in the budget
deficits can be achieved will therefore depend primarily on the feasibility of the increase
in non-mincral revenues. Even if revenues can be raised external financing will remain
crucial for balancing the Central Government budgeL
18
II. The Health Sector
1. Population and Urbanization
The population of Guinea has grown by 2.1 per cent during the period 1960-1988. In 1988,
the population reached 6.6 million. The fertility rate in 1988 is 6.2. Assuming an annual
population growth rateof2.6pcrcent(UNDP, 1990) over the period 1988-2000, the Guinean
population will amount to almost 9 million in the year 2000 (see table 6). Note that this
projected population growth rate is somewhat lower than that for Sub-Saharan Africa (3.1
per cent) and for the group of least developed countries (2.8 per cent).
Currently, about one quarter of the population lives in urban areas and about 12 per cent in
Conakry. In view of the growth rate of the urban population, viz. 5.2 per cent over the period
1988-2000, the share of the urban population in total population is projected to be 33 per
cent by the year 2000.
Lower Guinea has with 32.1 percent the highest number of inhabitants, followed by Middle
Guinea with 27.6 per cent of the population, Upper Guinea with 20.6 per cent and the Forest
Region with 19.7 per cent.
2. Health Status and its Determinants
The health status of the Guinean population is very poor even compared to that of other SubSaharan countries and low-incomecountries. The health status indicators presented in table
7 are life expectancy at birth (LE), the infant mortality rate (IMR) and the under-five
mortality rate (U5MR). Life expectancy at birth is reported to be42 in 1988. Infant mortality
rate and the under-five mortality rate are 146 per 1000 and 248 per 1000 in 1988. As can
be seen in table 7, these figures are considerably higher than the rates in comparable
countries. Still it can be observed that to some extent modest improvements in health status
were realized over the past two decades.
The main influences on health status are nutrition, safe water and adequate sanitation and
housing, education and health services including family planning and immunization
services. Selected indicators of these determinants are discussed next. First, it is generally
acknowledged that malnutrition is a major health problem in Guinea although data on the
extent and prevalence of nutritional deficiencies are not collected on a systematic basis.
Malnutrition is reported to be widespread among women, lactating mothers and young
children. The regions most affected by malnutrition are Upper and Middle Guinea due to
drought and recurrent pre-harvest food shortages. From table7, one sees that the daily calorie
supply is around 1,777 in 1986 and 1988. Note that the daily calorie supply as a percentage
of requirements is 77 percent in 1984-1986 (UNDP, 1990). The latter percentage is less than
the one reported for 1964-1966, viz. 81 per cent. It is also less than the percentages recorded
for Sub-Saharan Africa and the least developed countries in 1984-1986, viz. 91 and 89 per
cent, respectively. The precarious domestic situation thus explains the importance of food
imports. In 1984-1986, 14.4 per cent of the food available was imported. The food aid in
cereals in 1987-1988 amounted to 26,200 metric tons. The latter is about 9 times as much
as the average food aid per Sub-Saharan country.
Secondly, the population’s poor health status is influenced largely by the lack of safe water
and poor environmental and personal hygiene, particularly in rural areas. In 1985-1987, only
19 per cent of the population had access to safe water. The discrepancy between the rural
and urban areas is illustrated by the fact that 12 per cent and 41 percent of the rural and urban
19
GUINEA
MACROECONOMIC EVOLUTION & THE HEALTH SECTOR
population, respectively, had access to safe water. Also note that progress in safe water
supply has been very slow since 1975; in that year 14 per cent of the population had access.
Thirdly, the adult literacy rate is 29 per cent in 1985. Literacy among women is lower than
that among men: the literacy rate among females as a percentage of the literacy rate among
males is 43 per cent. It stands to reason that this inadequate degree of literacy hampers
advances in health status. The fact that especially women arc subject to a high degree of
illiteracy hinders the necessary improvement in the health and hygienic habits of households.
The health services arc an essential determinant of health status, of course. In view of its
importance, the health services structure isGuinea is discussed separately in the next section.
3. The Health Care System
a. Organization
The Ministry of Public Health and Population (Ministere de la Santd Publiquc et de la
Population, MSPP) is responsible for the formulation and implementation of national health
policy and for overall administration, coordination and management of the country’s health
system. The MSPP was created in January 1988 replacing the previous Ministry of Health
and Social Affairs. A chan depicting the organization of the MSPP is given in figure 2.
The regional managementof health care services is decentralized along the lincsofGuinea’s
administrative structure (figure 3). In each region, there is a medical officer (Inspection
Rigionale de la Sant£, IRS) who is responsible for inspection and coordination of health
services and other activities such as financial and administrative planning, in-service
training of staff and drug distribution.
In each of the 34 prefectures a director of health (Direction Prdfectoralc de la Santd) has the
task to support the primary health care programs in the subprcfcctoral health centers. For
instance, he receives orders for essential drugs from health centers and communicates them
to the National Primary Health Care Programme (Programme PEV/SSP/ME). In addition
he coordinates all health activities. The director is assisted by the head of the prcfectoral
hospital. At the sub-prefectoral level, the chief of the health center is also in charge of
supervising the health personnel in the sub-prefecture.
b. Types of Services
Publicly provided services
Public health services in Guinea are provided through a pyramid of facilities comprising 2
university hospitals, belonging to the Centre Hospitalier Universitaire (CHU), 6 regional
hospitals, 29 prefectoral hospitals and 344 subprefectoral health centers (MSPP,1990a).
The first formal entry point into the public health system is the subprefectoral health center.
The latter is designed to provide a variety of curative and preventive services, including
maternity and maternal and child health services, limited inpatient services, health and
nutrition education and outreach services. Health problems that cannot be dealt with at the
health center level are in principle referred to the prefectoral hospital. The six regional
hospitals and the two university hospitals provide tertiary care.
In one third of the subdistricts (sous-prfifectures), health centers were linked up with the
National Primary Health Care (PHC) Programme (Programme National PEV/SSP/ME) in
1989. The target for 1990 is that half of all health centers are covered by this Program. The
latter ensures that these health centers are supplied with essential drugs. The participating
health centers have also adopted a uniform cost-recovery scheme, whereby fees are
collected for the different health services provided, in particular the prescription and direct
provision of drugs to patients.
20
II. THE HEALTH SECTOR
A salient feature of the current cost-recovery system is that, at present, fee revenues are only
used in part for the financing of incentive payments to personnel and a limited amount of
operating costs. The bulk of revenues is accumulated in bank accounts. Certainly, health
centers have acquired the capability of budgeting health services and collecting and
administering fee revenues. However, as yet they have not reached the stage of effectively
utilizing the fee revenues in an autonomous way. Note, for instance, that important
expenditures items such as thecostof pharmaceuticals are in effect financed via the National
PHC Program.
The granting of further autonomy to health centers would have to be prepared cautiously,
however. In fact, oneof the outcomes of the study by Waty and Brudhon-Jakobowicz (1990)
on the budgets of health centers in Upper-Guinea, is that a large degreeof financial autonomy
(including the financial responsibility for the purchasing of drugs) would entail serious
financial problem s: half of the health centers would face bankruptcy or ha ve a budget deficit
Health centers would encounter such problems mainly because of excessive costs for
personnel (i.e. incentive payments) and other specific services in comparison to inadequate
fee revenues. In turn, the low level of revenues from fees can be explained by substandard
utilization of health services.
Whereas the health centers participating in the National PHC programme have acquired a
certain degree of autonomy so far, this is not the case of the university, regional and
prefectoral hospitals. They are directly administered by the MSPP. Also note that hospitals
charge a fee per consultation and per admission. However, in contrast to health centers, all
revenues have to be transferred to the treasury.
For drug supplies hospitals also depend entirely upon Pharmaguinee. The latter state-run
company is in charge of distribution of drugs to public health care institutions, especially
hospitals. Hospitals receive a budget allocation (erddit) from the Central Government The
latter allows them to buy pharmaceuticals at Pharmaguinee. In 1990, the value of drugs
distributed by Pharmaguinee amounted to 0.5 billion GF.
Non-publicly provided health services
The new Government has madecontinuousefforts to promote the participating of the private
sector, including non-profit organizations, in the development of the health system. For
instance, since 1985, 2 private clinics, 53 medical and dental practices, 5 laboratories for
biomedical analysis, 58 nursing practices, 128 private pharmacies and 28 private sales
outlets have been established. Private pharmacies and sales outlets are supplied by 6
wholesale traders. In addition, two private hospitals are run by bauxite companies in the
secondary towns of Kamsar and Bokd. The services provided at these hospitals are available
to the entire population living within their respective catchment areas, however. Also note
that some 6,000 traditional healers provide health services and several traditional birth
attendants attend deliveries in each village.
It is important to notice that some prefcctoral hospitals are managed jointly with non
government organizations such as Mddecins-sans-Frontiferes, Mddecins du Monde and the
Association Fran?aisc des Volontaires du Progrds. In contrast to the health centers, these
hospitals have obtained a large degree of autonomy in that they are able to utilize fee
revenues independently from the MSPP.
c. Levels of Services
Health Personnel
In 1984, the population per physician and per nurse were reported to be 57,400 and 6,400,
respectively. These ratios are among the highest in the world. Figures for 1988 are presented
in table 9. It can be seen that the number of physicians and nurses has increased drastically
21
GUINEA
MACROECONOMIC EVOLUTION & THE HEALTH SECTOR
since 1984. Indeed, 9,700 inhabitants per physician and 4,300 inhabitants per nurse have
been recorded. How this considerable increase in the number of health personnel has come
about is not entirely clear. Likely explanations arc that the health personnel statistics
reported for 1984 were underestimated and/or that Guinean health personnel that worked
in neighbouring countries returned to Guinea. Although the size of health personnel may
have expanded significantly, questions may be raised about the quality of medical education
and the competence of graduates. However, an assessment of the issue of quality can not
be made in view of the lack of information.
As can be seen from table 9, substantial differences exist in the distribution of health
personnel between the various regions. The region of Lower Guinea (Basse Guindc) is
endowed with the highest number of health personnel per population. Within the region of
Lower Guinea, the capital city of Conakry attracts major numbers of health personnel. In
fact in 1986, Conakry accounted for 12 per cent of the population and had 45 per cent of the
nation’s physicians, 58 per cent of pharmacists and midwives, and 39 per cent of nurses.
Health Care
Despite the involvement of many health centers in the National PHC Programme and the
policy of prescribing low cost essential drugs, the utilization of health services is relatively
low. We repeat that in their study about the functioning and financing situation of
participating health centers in Upper Guinea, Waty and Brudon-Jakobowicz (1990) point
at the rather low level of health services utilization. The ratio of consultations per person
per year is below 1 in 15 out of the 18 health centers. In only one health center does this ratio
exceed 2. Health centers also vary substantially in the total volume of health services. For
instance, the number of consultations per month varies between a minimum of 106 and a
maximum of 1122.
The health centers are also largely responsible for the administration of vaccines. The
percentage of infants under one year that was immunized against tuberculosis, polio, DPT
and measles in 1987amountsto23perccntonly.Thclattercomparesrather unfavorably with
theaverage for Sub-Saharan Africa, viz. 52pcr cent (UNDP, 1990).Notealsothatsignificant
differences in vaccination coverage across the country’s regions have been reported
(UNICEF, 1989).
A socio-economic evaluation of the National PHC Programme was started in November
1990. The results should contribute to a better understanding of the determinants of
utilization patterns and to the subsequent adjustment of health policies.
Hospitals are especially characterized by excess supply of personnel. The two university
hospitals in Conakry have almost one member of health personnel per hospital bed. In the
regional hospital of Kindia, the size of health personnel amounts to 119 (of which 22 are
physicians) whereas the number of beds is 100. There is also excess supply of personnel in
prefectoral hospitals. For instance in the prcfectoral hospitals of Fria and Mamou, there are
13 and 11 physicans relative to 60 and 54 beds, respectively. Despite the relative abundance
of personnel, patients’ utilization of services is low. Indeed, the average occupancy rate in
the prefectoral hospitals of Lower Guinea, Middle Guinea, Upper Guinea and the Forest
Region amount to 19.4,28.1,22.76 and 22.74 per cenu respectively. In the other hospitals,
the average occupancy rate is 32.1 per cent (MSPP.1990). One of the major causes of low
utilization ofservices is the poor quality of services. Especially the shortage of pharmaceuticals
and the lack of hygiene in hospital buildings contribute to this substandard quality.
22
II. THE HEALTH SECTOR
4. Health Financing
Four main sources of financing health care exist in Guinea: the MSPP budget and local
government budgets, external assistance and household budgets.
a. Central Government Health Expenditures
Level of Expenditures
Health expenditures in current GF rose by a factor of eight from GF .957 billion in 1985 to
GF7.412billionin 1990(table 10). Real health expenditures, using the consumer price index
for deflating the expenditures, increased on average by 24 per cent per annum between 1986
and 1989. This trend of rising health expenditures stopped in 1990. In this year real health
expenditures as budgeted will decrease by 5 per cent, assuming the inflation rate will equal
the targeted inflation rate of 16 per cent. However, it seems that due to the rise in fuel costs
last August and pressures on public and private sector wages, the chances of holding the
inflation rate below 20 per cent in 1990 are jeopardized (EIU, 1990). In other words, the
decrease in real health expenditures risks to be larger than 5 per cent.
An alternative price deflator for health expeditures worth considering is the subcomponent
of the consumer price index for health and hygiene. Unfortunately, it is only available for
1986 and 1987. When using this deflator, the real increase (decrease) in health expenditures
is smaller (greater) than the one calculated using the consumer price index: real spending
decreased by about 6 per cent in 1986 (instead of an increase of 53 per cent) whereas an
increase of 6.3 per cent is computed for 1987 (instead of an increase of 14 per cent).
Note from table 10 that the ratioof health expenditures to govemmentexpenditures has been
about 5 per cent in 1989 and 1990. The ratio of health expedi ture to GDP, which is a measure
of the domestic resources allocated to publicly provided health care is less than half a per
cent.
Structure of Expenditures
The largest part of government health budget is allocated to current expenditures: the latter
amount to 68.3 and 72.8 per cent of health expenditures in 1989 and 1990, respectively. The
salary component accounts for about 60 per cent of current expenditures in 1989 and 1990.
The share of the expenditures for pharmaceuticals in the latter years is about 19 per cenL
Basic salaries of health personnel are quite modest. The basic salary of a nurse and a
physician amount to 30,000 GF (USS 44) and 60,000 GF (USS 88), respectively. However,
a general increase in salaries can only be envisaged when the government is committed to
increasing the overall health sector budget A fortiori, without an upward adjustment of this
budget a salary increase would provoke a decrease in the budget for pharmaceuticals,
supplies and other operating costs. In particular as drugs and supplies are already very often
unavailable in hospitals, such a policy would lead to serious shortages of medicines and a
further decrease in the quality of care.
b. Local Government Health Expenditure
Local governments allocate part of their own budgets to the health sector to finance salaries
of selected categories of personnel (in particular maintenance workers) and to defray other
operating costs. The largest part of these expenditures is financed through local tax revenues
(ristoumes) and a smaller part through direct contributions by the Central Government. In
principle, local governments such as those of prefectures allocate 30 per cent of their tax
revenues to health and education.
23
GUINEA
MACROECONOMIC EVOLUTION & THE HEALTH SECTOR
The annual health expenditures at local government level arc estimated at about GF 225
million. This represents only a modest contribution compared to the current expenditures
budgeted by the Central Government, viz. 4.433 and 5.396 billion GF in 1989 and 1990,
respectively.
c. External Aid
Guinea did not, until about 1983, receive external aid for health care. However, in recent
years external financing rose considerably. According to the World Bank (1987), external
assistance amounted toUSS7.8million or USS 1.3pcrcapitaduringthe period 1983 to 1986.
As can be seen in table 10, external aid finances the bulk of capital expenditure in the health
sector. In fact, external aid finances 82.4 and 85.9 per cent of total capital expenditures in
1989 and 1990, respectively. Most of the external funding is provided by multilateral
institutions such as the European Community’s Fonds Europdende Ddveloppemcnt (FED),
the World Bank, UNICEF and WHO. Note especially that the drug distribution component
in the National PHC Programme is financed almost exclusively via grants from UNICEF
and the Italian GovemmenL These grants are included in total capital expenditures; they
amounted to approximately USS 1.8 million over the period 1986-1990. The World Bank
has also extended an IDA credit of USS 19.7 million (covering the period 1986-1991) to the
Guinean Government in order to develop health services in health centers and prefectoral
hospitals, especially in rural areas.
d. Households
Households take part in the cost-recovery of publicly provided health services. At the
subprcfectoral health centers that are pari of the National PHC Program, patients contribute
to cost-recovery via fees. The fees cover the costs of essential drugs provided at the health
center. Fee levels depend upon the type of treatment. For instance, treatment against malaria
in children and adults costs GF 50 and GF 100, respectively; treatment against sexually
transmitted diseases such as gonorrhea and syphillis by means of pencillin-procaine costs
GF 2,000. It is estimated that in 1989 household expenditures on essential drugs amount to
USS 823,194 or 0.494 billion GF; in 1990, these expenditures amount to US S 1,527,372
or 1.039 billion GF. It is projected that these expenditures will rise to USS 2,172,042or 1.477
billion GF in 1991 (UNICEF, 1989).
Despite the participation in the National PHC Program, whose management of drug supplies
is quite adequate, health centers may lack specific drugs from time to time. Health centers
may run out of stock due to inadequate stock management; they may also underestimate the
time thatelapses between theordering of drugs and their arrival at the health center. Shortage
of drugs at health center levels may thus enhance the purchasing of pharmaceuticals at
private pharmacies or outlets.
Households contribute in a limited way to the financing of publicly provided health services
at hospital level. Flat fees are charged per consultation (GF 100) and per week of
hospitalization (GF 3,000). Drug availability at hospital level is very limited. Hence, many
times patients receive prescriptions and have to buy the necessary drugs outside the public
sector. The low drug availability is likely to be one of the causes of the low utilization rates
of hospital services. In view of the low occupancy rates mentioned above, revenues from
hospital fees are rather limited. For instance, revenues collected by the two university
hospitals in Conakry amounted to GF 117,600,000 in 1990. The latter amount represents a
mere 2 per cent of that year’s current government health expenditures.
We reiterate that in view of the problems with drug availability at state-run hospitals and
health centers, patients may have to acquire pharmaceuticals at private pharmacies. The
country’s imports of pharmaceuticals are supplied to private pharmacies and outlets via the
24
II. THE HEALTH SECTOR
six wholesale traders. The value of sales of imported drugs amounted to 1.32 billion GF in
1989. Guinea also has a number of pharmaceutical companies, such as Soguipharm and
Eniphargui, that manufacture a selected number of essential drugs for private sale. Note that
Soguipharm also sells part of its production, viz. 10 per cent of its total sales amount, to
Pharmaguincc. It is interesting to observe that Soguipharm’s sales volume is about identical
to the value of drugs distributed by Pharmaguincc to public hospitals.
As said above, a number of hospitals are managed jointly by NGOs and the state. These have
acquired an important degree of autonomy. Apart from having established their own cost
recovery schemes, these hospitals would also have their own channels of drug distribution.
Most often the purchase of essential drugs is organized by the NGOs via international
tenders. The availability of drugs at these hospitals is usually very adequate. This explains
in part the high utilization rates observed. In turn the latter explains why the amountof costs
recovered by such hospitals is quite important. For instance, the fee revenues collected at
the hospital of NzdrdkonS (which is co-managcd by MSF-Belgium) amount to 165,000,000
GF.
It is thus apparent that households’ health expenditures are highly significant vis-il-vis those
of the government. For instance, in 1989, the sum of the sales of drugs at health centers
participating in the National PHC Programme and the value of imported drugs amounted
to 1.814 billion GF. The latter already represents 41 per cent of current government health
expenditures. Other evidence of the importance of households’ health expenditures comes
from an expenditure survey heldamong300 households in Conakry in the period 1986-1988
(Fandre, 1990). It was found that the shares of health expenditures in total expenditures
amounted to 16 and 9 per cent in 1986 and 1988, respectively.
5. Sector Policy and Strategy
The current inadequacy of the public health system is emphasized in the “Declaration of the
Government of Guinea’s Development Policy” (World Bank, 1988, Annex V). The
Government considers it unacceptable to allow the health and education sectors to
deteriorate further given the very low levels of the social indicators and the scant resources
allocated to these sectors. Therefore theGovemment expects to assign high priority to these
sectors when preparing the budget of current and capital expenditures and to increase their
allocation. The Government is implementing a plan of action for the health sector that
emphasizes primary health care: protection of mothers and children, vaccination programs
and hygiene.
The Government’s specific objectives till the year 2000 are:
to ensure the coverage of 80 per cent of the population by health centers;
(i)
to
(ii)
renovate the sub-prefectoral health centers;
to
(iii)
renovate and reequip 22 prefectoral hospitals, and the 4 regional hospitals;
to
(iv)
ensure the supply of essential drugs;
to extend and improve cost recovery;
(v)
to
(vi)
integrate traditional medicine into the health system;
to
(vii)
ensure the training ofpersonnel in view ofprimary health care.
For specifying the financial requirements of its action plan, the Government has preprared
a budget plan for the years 1990 to 1992 to be presented in section III.3.
25
GUINEA
MACROECONOMIC EVOLUTION & THE HEALTH SECTOR
III. Implications of Macroeconomic
Developments for the Health Sector
1. Effects on Nutrition Status and Health Outcome
Guinea was shown to have low levels of social indicators (Section II). They are as low or
even lower than the indicators for the poorest countries in Sub-Saharan Africa. Therefore,
any further deterioration of the nutrition and health status is declared inadmissable by the
Government
One of the main characteristics of the economic and financial reform in Guinea has been
a shift in relative prices at the expense of the public sector but in favor of the rural and private
industry and service sector. A result of this shift has been an increase in agricultural
production and a substantial expansion of theactivity of small-scale enterprises and services.
Accordingly, the increase in per capita income of about 1.6 per cent per annum in recent
years was concentrated in theprivate and rural sectors. Similarly, employment has expanded
in the private sector while it has decreased in the public sector. Given this basic economic
evolution, the nutrition status and therefore the health status can be expected to stabilize or
even improve for the groups employed in these sectors of the Guinean economy.
Apart from these positive effects theeconomic and financial reform is likely to have adverse
impacts on the health status of specific segments of the Guinean population. The negative
effects of the economic reform include: lay-offs of civil servants and public enterprise
employees, and losses in purchasing power as a result of price increases of food products,
rents, water, electricity and health services. The most vulnerable groups in the urban areas,
and specifically in Conakry, include unemployed civil servants, unemployed former
employees in public enterprisesand unemployed graduates. Note that the purchasing power
of civil servants has been reported to have decreased substantially and unemployment
appears to have increased in urban areas in 1989 (Section I.2.b). The rural area groups and
regions that do not share in the rise of agricultural output are most likely negatively affected
by the economic changes. These groups face losses in their purchasing power due to rising
expenses that are not compensated by rising income.
To mitigate the adverse effects of the economic reform the Guinean Government has
incorporated a social policy component into its reform programme (Section 1.3.a). Whether
the nutrition and health status of the most vulnerable groups will deteriorate depends
importantly on the efficacy of the social policy measures and on the extent to which
unemployed are absorbed by the private sector. For civil servants, for example, who are not
taken over by the newly organized public administration the Government has instituted
severance packages. The severance payments are transitory and will stop in 1991, however.
Discontinuing these severance payments would constitute an important hardship for civil
servants who are still umemployed. That this is a relevant issue seems to be indicated by the
recent increase in unemployment
NGOs are considered to haveaparticularly importantrole in meeting the needsof vulnerable
groups during the economic adjustment process. In this way they complement the social
policy measures of the Government
26
III. IMPLICATIONS OF MACROECONOMIC DEVELOPMENTS FOR THE HEALTH SECTOR
2. Effects on Health Service Delivery
a. Central Government Health Expenditures
An important objective of the economic reform is the control of government expenditures.
Accordingly, the Government plans to have a budget deficit not larger than 3 to 3.5 percent
of GDP per annum in the coming years. It also plans to keep real Central Government
expenditures constant. The latter implies that real health expenditures would only be able
to increase as soon as other components of government expenditure are reduced. Note,
however, that capital expenditures in the health sector would be less sensitive to the
govcmmcnt’sbudgetarypolicy,as80pcrccntofallcapital health expenditures is externally
financed.
It has in fact been the declared objective of the Government to attribute a high priority to
the health sector and to increase the share of health in the overall budget. However, while
this policy has been followed in the years 1986 to 1989, less importance appears to have been
given to the health sector in 1990. Notice in table 10 that the share of health expenditure in
overall government expenditures will decrease in 1990. Assuming an inflation rate of 16 per
cent, real health expeditures in GF will drop by about 1.8 percent As the inflation rate will
most likely be closer to 25 percent, real health expenditures could be reduced by up to 11
per ccnL In other words, these findings are at variance with the Government’s official
objective of safeguarding the health sector.
As the real health budget has come to be severely limited, it is all the more important that
one makes a cost-effective use of the available resources. In other words, it is imperative
to strive for an optimal combination and size of inputs into the health sector. Let us cite
especially that human resource planning is needed in view of containing health personnel
costs and leaving room for financing other necessary inputs. For instance, assuming the size
of health personnel remains constant, a decrease in real health expenditures will have an
adverse effect on the budget for complementary inputs such as pharmaceuticals. Given the
current lack of medicine in public hospitals, the present allocation decision will only
exacerbate the serious problems in delivering adequate health services.
Note that the present shortage of medicine is a consequence of the decision to allocate a
relatively low sharcof the government budget to health. However, it is alsoaresultof arecent
exchange rate policy. In fact, an important component of economic policy has been the
devaluation of the Guinean Franc by about 107 per cent in the period 1986-1989. As drugs
(and other equipment) are in general imported and as the devaluation has been passed
through to domestic prices, the expenses for medicines increased substantially. The latter
is reflected in the strong increase of the subcomponent of theconsumer price index for health
and hygiene. It follows that this devaluation reduced the purchasing power of the
government budget for pharmaceuticals. Note that the decline in the real budget for drugs
concerns especially the hospital sector, as drugs in the National PHC programme are
financed by outside sources.
b. Household Expenditures and Cost-recovery
The relative economic improvement of some segments of the population may create a
greater potential for cost-recovery among households for publicly provided health services.
For instance, the rural population that benefits from the boost in agricultural production
should be able to have greater access to the health centers participating in the National PHC
Programme. However, groups that face adverse economic effects may be in a difficult
position to pay user fees.
27
GUINEA
MACROECONOMIC EVOLUTION & THE HEALTH SECTOR
Discussions arc underway at the MSPP about introducing acost-rccovery scheme at the level
of public hospitals. It will be very important to determine patients’ contributions such that
access to health services can be insured. In view of safeguarding the utilization of health
services by the most vulnerable groups, exempting them from payment of contributions or
fees may well become necessary.
c. Resource Needs and Financing
In its National Plan for the Development of the Health Care System, the MSPP proposes a
series of projccLs whose overall cost for the period 1990-1992 amounts to USS 76.241
million or GF 51.844 billion (Table 11). Of the latter amount, 10.8 and 10.9 per cent would
be financed by domestic and external sources, respectively. Financing for about 78 per cent
of the cost still needs to be found.
The Guinean Government would finance GF4.245 billion of the domestically financed part,
or GF 1.415 billion on an annual basis. Under the assumption that these expenditures would
occur in addition to the regular government budget, the budget for health expenditures in
1990 would have to be at least 7.9 billion GF (= 6.489 billion GF + 1.415 billion GF). The
amountbudgeted for 1990 is7.412 billion, however. In other words, the health expenditures
budgeted for 1990 are 6.2 per cent below the theoretically required amount. Also notice that
total health expenditures (including externally financed expenditures) as a share of total
government expenditures drops from 5.0 per cent in 1989 to 4.7 per cent in 1990. The share
of current health expenditures in current government expenditures reduces from 2.8 per cent
in 1989 to 2.6per cent in 1990. It thus seems that the Government takes decisions with respect
to the health budget that are in contradiction with the announced policy.
It is important to note that, apart from the shortfall in government resources, there is a further
need to find additional funds to finance USS 60.553 million or41.156 billion GF over the
period 1990-1992. Under the assumption that it is possible to cover this financing gap (USS
20.174 million on a yearly basis) by external resources, this aid amount would represent an
increase of 11.4 per cent of total ODA to Guinea in 1986. As a matter of comparison, the
increase in ODA from 1986 to 1987 amounted to about 22.4 per cenL It follows that about
half of this increase in total ODA would be needed to finance the financing gap in the
National Plan.
28
IV. Implications for Actions
A first important issue in health policy for Guinea will be to ensure the financing of theplan
for the development of the health care system for the period 1990-1992. It appears that there
is no guarantee that the Central Government will be forthcoming with the necessary funds.
In addition, a substan ti al financial gapexists for which financing has still to be sought. Given
the prescntstateofcommitment from the national government and thelimitation on external
resources, it is doubtful whether funding for the ‘principal’ and ‘additional’ proposals can
be ensured in the short run. Therefore, a realistic reassessment of the plan may be required.
Secondly, the overall role of health within the central government budget needs to be
carefully scrutinized. Note that the share of current health expenditures in total current
government expenditures is relatively low. Discussions are needed about the possibility of
reallocating funds from other sectors, such as defense, to health. However, even if a larger
share would be attributed to health, government health expenditures per capita will remain
modest in the coming years. Thus, it is imperative that resources are used as efficiently as
possible. The proper mixofinputs financed by the health budget needs also to be examined.
For instance, a su i table balance between expenditures on heal th personnel and complementary
inputs such as drugs and equipment is required.
Thirdly, a challenge for the coming years is to identify to what extent recovery of costs of
health scrviccsamong houscholdscan be instituted. Astrategy of cost-recovery isadvisable,
but only if it can contribute toa better provision of quality heal th care and to a more equitable
pattern of utilisation of health services. It is hoped that the results of the evaluation of the
National PHC Programme would facilitate the formulation and/or adjustment of cost
recovery policies at the primary health care level. As the MSPP also considers the
implementation of cost-recovery at the hospital level, much attention will have to be paid
to the way fees or other forms of patient contributions are established as the latter have an
impact on the utilisation pattern of health care services across socio-economic groups.
Fourthly, the specific measures of the social policy component in the second phase of the
economic reform include the protection of vulnerable groups against expenditure cuts,
particularly in the health and education sectors, the continuation of severance packages to
civil servants leaving the public administration, and the improvement of the Government’s
capacity to monitor living standards of the population during the adjustment process. The
commission that supervises the implementation of the social policy at the ministerial level
is the National Commission on Social Policy (CNPS). As the social policy programme is
of key relevance to the health sector the institutional development of the CNPS should be
closely observed and an adequate participation of the MSPP in the formulation and
implementation of the social policy should be ensured.
The monitoring of the impactof the structural adjustment programme on the living standards
of households is of specific concern to the MSPP as it helps to identify vulnerable groups
who are mostly in need of health services. The results of households surveys that are to be
organized on a regular basis should be considered as an important input into the formulation
of health policies.
29
GUINEA
MACROECONOMIC EVOLUTION & THE HEALTH SECTOR
V. Acronyms and Abbreviations
AfDF
- African Development Fund
CNPS
- Commission Nationale de Politique Sociale
DAAF
- Directors of Administration and Financial Affairs
DPS
- Directeur Prefectoral de la Santd
EFCC
- Economic and Financial Coordination Committee
IRS
- Inspecteur Regional de la Sante
MEF
- Ministere d’Economie et de la Finance
MPCI
- Ministere du Plan et de la Cooperation Internationale
MSPP
- Ministere de la Sante Publique et de la Population
NPTF
- National Poverty Task Force
ODA
- Official Development Assistance
PAGEN II - Second Economic Management Support Project
PHC
- Primary Health Care
PIP
- Public Investment Program
SAF
- Structural Adjustment Facility
SAL
- Structural Adjustment Credit
SAP
- Structural Adjustment Programme
SPA
- Special Programme of Assistance
SED
- Secretariat d’Etat a la Decentralisation
SEDSP
- Socio-Economic Development Support Project
WFP
- World Food Program
30
VI. References
Economist Intelligence Unit, Economic Structure Guinea,
Country Report, 1990, no.4, London.
Economist Intelligence Unit, Country Profile Guinea 1990-1991,
1990, London.
Fandre C., Conditions de Vie desMenages d Conakry 1986-1988,
Revue de la Mission De Cooperation et d’Action Culturelie en Guinee, May 1990, no.2.
FAO (1989), Rapport du Programme de Soutien a I’lnvestissement,
No. 146/89 IF-GUI27, Novembre, Rome
Guyon A.,Carlevaro P. and Abegue Sa Oyono (1989),
Evaluation du Programme PEVISSPIME en Republique de Guinee,
UNICEF, 25 May-9 June 1989, Draft.
IMF (1987), Guinea, Recent Economic Developments, Washington.
LacroniqueJ.F. and D. Mrejen (1990),
Rapport de Mission en Guinee, Minist&re de la Cooperation et du Developpement,
France.
Ministere de 1’Economie et des Finances (1989), Loi de Finances pour 1990.
Ministere de 1’Economie et des Finances (1990), Projet de Budget Remanie de I'Etai 1990,
24 July 1990.
Ministere de 1’Economie et des Finances (1990), Preparation du Projet de Loi de Finances pour
1991.
MSPP (1988), Tableau de Purification des Soins dans les Centres de Sante de Sous-Prffecture,
Programme National PEV/SSP/ME.
MSPP (1989a), Plan National de Developpement Sanitaire (Propositions de Financement),')
ICO/GUI/90.1, Avril 1990.
MSPP (1989b), Plan Triennal a I’Horizon Glissant pour la Periode 1990-1992 (Draft).
MSPP (1990a), Annuaire Statistique 1989,
Bureau des Etudes, Planification, Recherche, May 1990.
MSPP (1990b), Joumees de Reflexion sur la Politique Hospitaliere,
GUINEA
MACROECONOMIC EVOLUTION & THE HEALTH SECTOR
Conakry 28-30 Avril 1990.
OECD (1989), Geographical Distribution of Financial Flows to Developing Countries,
Paris.
UNDP (1990), Human Development Report 1990,
Oxford University Press, New York.
UNICEF (1989), The State of the World’s Children 1990,
Oxford University Press, Oxford.
Waty M-O.(1989), Analyse du SystUme de Recouvrement des Couts,
Rapport d’une Mission, Mars 1989, Programme National PEV/SSP/ME, Republique de Guinfe.
Waty, M-O. and Pascale Brudon-Jakobowicz (1990),
Rapport d’ une mission OMS,ffvrier. Programme national
PEV/SSP/ME, Republique de Guinde.
WHO (1989), Global Strategy for Health for All, Monitoring 1988 -1989,
WHO/HST/89.1, Geneva, May.
World Bank (1987), StaffAppraisal Report, Guinea, Health Service Development Project,
March 10.
World Bank (1988),
Report andRecommendationofthePresident ofthelnternationalDevelopment Associations the
Executive Directors onaProposedCreditofSDR47millionto the Republic ofGuineafor aSecond
Structural Adjustment Program,
Washington, D.C., May 24.
World Bank (1989a),
StaffAppraisal Report, Republic of Guinea, Socio-Economic Development Support Project,
Washington, D.C., March 9.
World Bank (1989b), Country Brief,
Guinea, December.
World Bank (1989c), World Development Report 1989,
Oxford University Press, Oxford.
32
S'
w
w
MAP MJ 3022 H»v 7
NfWFMBFR IM5
UNITFD NATIONS
GaOual/ V)
Amali
JKaybii® j/
4-aT*
]j DINGUIRAYE t-
'
Konfara^J
VI. Map of Guinea
L
GUINEA
MACROECONOMIC EVOLUTION & THE HEALTH SECTOR
VII. Annexes
Table 1
Gross Domestic Product by Sector of Origin, 1986-88
(%, in billions of GF)
1986
1987
1988
1989
1990
V
Growth Rates (% per annum)
(from constant price data)
GDP
6
5.9
4.3
Agriculture
4.2
4.8
5.7
Industry
7.5
6.8
2.1
of which manufacturing
3.8
5.8
1.6
Services
4.9
5.9
5.1
Shares of Gross Domestic Product (%)
(from current price data)
GDP
100
100
100
100
Net Indirect Taxes
1.3
1.6
1.6
1.6
Agriculture
30.7
29.4
29.1
29.5
Industry
31.3
33
33.3
32.6
of which manufacturing
5.5
3.5
3.5
3.4
Services
38
37.6
37.6
37.9
671
902
1151
1430
Memorandum item:
GDP, current prices
1760
Source: World Bank (1989b)
35
GUINEA
MACROECONOMIC EVOLUTION & THE HEALTH SECTOR
ANNEXES
Table 2
Consumer Price Index, 1985-89
(Dec. 1986 = 100)
. .... .
SWISSiSiaiiliilMSiiiiilIS
Dec.
1985
Dec.
1986
Dec.
1987
Dec.
1988
100.0
133.7
169.0
71.8
33.7
26.4
100.0
143.0
33.9
43.0
100.0
144.7
130.9
44.7
100.0
131.8
Rate of change (%)
223.6
31.8
Electricity & Water
100.0
95.4
Total
58.2
Rate of change (%)
Food
74.7
Rate of change (%)
Health & hygiene
43.3
Rate of change (%)
Housing
30.9
Rate of change (%)
Dec.
1989
-4.6
Memorandum item:
Consumer Price Index
(period average)
100.0
Rate of change (%)
Implicite GDP Deflator
Rate of change (%)
Source: IMF (1987.1988); World Bank (1989b)
36
76.7
136.7
174.2
223.3
36.7
27.4
28.2
100.0
120.7
163.4
20.7
35.4
GUINEA
MACROECONOMIC EVOLUTION & THE HEALTH SECTOR
ANNEXES
Table 3
Balance of Payments, 1986-90
(in millions of USS)
1986
CURRENT ACCOUNT BALANCE
Excl. official transfers
Trade Balance
Exports, f.o.b.
Of which: Bauxite & aluminia
Imports
Of which: Public sector
Service & Priv. Transfer
Non-factor services,net
Factor services, net
Private transfers, net
-54.0
-96.3
141.5
603.5
467.2
-462.0
-204.3
-237.8
-79.6
-144.1
-14.1
Official transfers
CAPITAL MOVEMENTS
Public capital, long term
Public capital, short term
Mixed mining comp.
Other priv. cap.l incl. direct invest.
Errors and omissions
OVERALL BALANCE
FINANCING
42.3
36.9
49.8
-15.2
-2.7
5.0
-34.9
-52.0
IMF credit
Disbursement & Purchase
Of which: SAF
Repayment & repurchase
Gold
Other reserve movements
Changes in arrears
Reduction of arrears
Accumulation of arrears
Other liabilities
1986 Paris Club resch.
Other debt resch.
1989 Paris Club resch.
52.0
10.9
17.6
0.0
-6.7
-23.3
-274.8
-285.3
10.5
-13.5
219.2
133.5
0.0
1987
1988
-74.5
-157.3
137.8
628.4
484.8
-490.6
-176.9
-295.1
-210.3
-293.8
11.6
603.3
454.5
-591.7
-191.1
-305.4
-121.0
-136.1
-38.0
82.8
71.6
50.4
-110.0
-168.6
-26.8
1989
1990
Estimat
Proj.
-125.5
-223.3
144.0
721.0
530.6
-577.0
-180.3
-367.3
-129.0
-200.9
-47.4
-83.3
-199.9
188.7
799.6
613.4
-610.9
-209.5
-388.5
-110.7
-242.1
-35.8
116.6
114.1
96.6
0.0
6.6
10.9
0.0
30.9
-30.9
2.4
14.6
21.9
14.6
0.0
97.8
89.5
70.9
0.0
8.6
10.0
-1.5
-37.2
37.2
17.2
0.0
0.0
22.5
22.5
-7.3
-9.2
-34.0
7.5
-5.3
-18.4
-16.5
24.0
0.0
-19.6
42.0
57.0
-19.0
76.0
-20.5
-88.5
-104.7
16.2
0.0
6.3
25.5
0.0
0.0
43.7
0.0
0.0
30.9
0.0
13.2
0.0
0.0
116.5
0.0
0.0
16.0
5.2
-8.2
-10.7
10.7
83.5
73.7
38.0
0.0
29.3
6.5
13.6
-123.1
123.1
14.9
14.9
-12.5
-24.0
-8.7
-13.8
-19.8
6.1
0.0
Source: World Bank (1989b)
37
GUINEA
MACROECONOMIC EVOLUTION & THE HEALTH SECTOR
ANNEXES
Table 4
Government Budget, 1986-90
(in billions of GF, %)
Revenue and grants
Tax revenues
Mining sector
Non-mining sector
of which:on income & profits
of whichron goods & service
of which:on intern, trade
Non-tax revenue
Grants
Total expenditure
Current expenditure
Wages & salaries
Goods & services
Susidies & transfer
of which:severance payments
interest paymenst due
Capital expenditure
Deficit,commitment basis
Changes in ext. arrears
Changes in dom. arrears
Deficit, cash basis
Financing
Foreign financing, net
Domestic financing, net
Memorandum item:
1986
1987
1988
94.9
73.4
62.2
11.2
1.1
4.1
161.1
188.8
111.4
90.4
21.1
6.0
8.3
12.8
136.2
85.2
18.2
9.0
14.9
34.8
192.2
107.3
21.3
51.8
16.0
3.5
18.2
127.3
89.1
38.2
2.9
23.7
11.7
23.3
38.1
271.3
147.9
45.5
48.0
22.9
5.0
31.4
84.9
-31.1
-5.3
123.5
-82.5
12.2
-38.6
3.7
-32.7
1.0
-69.4
38.6
32.8
36.7
38.3
-5.5
69.4
65.4
45.0
9.5
0.0
12.5
51.0
-41.8
3.2
0.0
1.8
Changes in expenditure
Inflation rate (period average)
Deficit (commitment) as % of GDP
1.6
10.4
179.4
251.7
140.8
110.9
56.9
56.9
109.9
69.5
4.6
40.5
13.5
10.2
58.3
322.9
156.8
55.7
52.9
15.9
0.7
32.3
166.1
-85.2
-16.9
-9.2
21.5
21.0
58.0
418.5
205.5
77.1
70.5
22.7
2.5
35.2
208.0
-86.1
-6.8
-2.5
-95.4
99.4
4.0
19.0
28.2
29.6
36.7
41.2
27.4
-3.5
-7.2
-5.2
-4.9
Source: World Bank (1989b); Ministere de I'Econmie et des Finances (1989)
38
1990
Proj
327.4
-111.3
111.3
89.8
-3.0
41.1
-6.2
1989
Est
237.7
71.3
-10.8
16.0
MACROECONOMIC EVOLUTION & THE HEALTH SECTOR
GUINEA
ANNEXES
Table 5
Official Development Assistance, Net, 1984-88
(in millions of USS)
1984
1985
1986
1987
1988
Bilateral Aid
42.2
52.5
95.2
142.4
184.5
Canada
9.8
11.2
2.8
4.8
6.6
Denmark
3.4
0.7
3.6
2.9
1.1
France
9.4
20.0
35.9
51.0
86.8
Germany, F.R.
8.5
6.7
11.6
24.8
11.4
Italy
3.3
3.2
7.0
7.6
31.4
Japan
2.7
5.0
3.2
22.5
26.6
United States
4.0
8.0
12.0
23.0
13.0
Others
1.1
-2.3
19.1
5.8
7.6
Multilateral Aid
51.3
57.5
67.1
70.6
80.0
Af.D.F.
1.1
7.6
12.0
13.6
9.5
E.E.C.
13.9
10.4
15.0
13.3
10.7
-5.0
-7.8
-10.0
-12.0
43.0
IBRD
IDA
19.8
21.5
35.5
38.2
IFAD
0.3
3.3
4.4
2.8
UNDP
5.2
4.4
5.8
6.9
10.9
UNICEF
1.0
0.9
1.0
1.6
1.5
WFP
2.1
0.9
1.4
2.0
2.5
Arab Agencies
4.8
5.5
-2.6
0.5
7.1
Others
3.2
8.0
2.4
1.7
6.8
Arab Countries
29.7
2.1
4.4
12.0
13.6
123.2
112.1
166.6
225.0
278.1
Total
Source: OECD (1990)
39
ANNEXES
MACROECONOMIC EVOLUTION & THE HEALTH SECTOR
GUINEA
Table 6
Population, 1985-2000
(millions, %)
<•
Urban
X
Rural
1985
6.201
1986
6.331
1987
6.464
1988
1.587 (24%)
5.053 (76%)
6.600
1989
6.772
1990
6.947
1991
7.128
1992
7.314
1993
7.504
1994
7.699
1995
7.899
1996
8.104
1997
8.315
1998
8.531
1999
8.753
2000
8.989
1 Population figures starting in 1990 are medium projections.
Source: MSPP (1989)
40
Total(l)
GUINEA
■
MACROECONOMIC EVOLUTION & THE HEALTH SECTOR
ANNEXES
Table 7
Nutrition and Health Status
(Sub-Saharan Africa/Low-income countries)
1965
1982
1985
1986
1988
1777
1776
(2095/2392)
NutritionStatus
daily calory
supply
(cal. p. person)
1923
(../1993)
daily protein
supply
(grams p. person)
40
40
(52/57)
Health Status
life expectancy
at birth
35.1
42.2
(50.6/61.4)
IMR
(p. 1000 live b.)
196
146
(113.6/72.6)
U5MR
346
(1960)
248
(173.4/174.8)
Source: World Bank (1989c); UNICEF (1989).
41
GUINEA
■
ANNEXES
MACROECONOMIC EVOLUTION & THE HEALTH SECTOR
Table 8
Access Indicators
(Sub-Saharan Africa/low-income countries)
1984
1981
1985
1987
1988
Safe Water
(% of population)
Total
19.0
(36.5/...)
Urban
41.0
(75.5/73.4
Rural
12.0
(24.2/...)
Medical Care
Population per
- physician
- nurse
54,430
57,390
(1965)
(.75410)
4,750
6,380
(1965)
(.72150)
9.700(1)
4,300(1)
Infants immunized
(%)
16.0
-DPT
(45.7/41.3
27.0
- Measles
15
(52.9/43.4
16.0
- Polio
(-.7...)
31.0
-BCG
(..7...)
31.0
-TB
(..7...)
Access to local health care (%)
1 Figures reported in MSPP (1989a);
Source: World Bank (1989c); UNICEF (1989).
42
13
GUINEA
MACROECONOMIC EVOLUTION & THE HEALTH SECTOR
ANNEXES
Table 9
Regional Distribution of Medical Personnel in 1988
(Population per Medical Personnel!)
Categories
National
Level
Lower
Guinea
Middle
Guinea
Upper
Guinea
Forest
Region
Physician
9700
4700
21500
17800
19200
Chemist
50300
31300
112800
61400
51600
Dentist
384700
161200
450000
1290000
Midwife
18600
7800
106000
61400
28600
Nurse
4300
2500
12100
7400
3700
Source: MSPP (1989a)
43
MACROECONOMIC EVOLUTION & THE HEALTH SECTOR
GUINEA
ANNEXES
Table 10
Central Government Health Expenditure, 1985-90
(in billions of GF, %)
1985
1986
< ::
1987
1988
1989
Estimat.
1990
Proj.
0.957
2.151
3.247
4.872
6.489
7.412
Current exp.
4.433
5.396
Of which:Salaries
2.700
3.227
Of which:Pharmaceutic.
0.850
1.000
Of which: Others
0.883
1.169
Capital exp.
2.056
2.016
Capital expenditure
(financed externally)
9.603
12.306
Expenditure
Changes in
nom. expenditure
124.8
51.0
50.1
33.2
14.2
real expenditure
53.0
14.3
23.7
5.2
-1.8
H.exp./Gov. exp.l
5.0
4.7
Cur.hlth exp./cur. exp.2
2.8
2.6
Cap. hlth exp.3 /cap. exp.
7.02
7.83
0.40
0.37
Health exp. /GDP4
0.32
0.36
0.42
1067
Health, exp. per
733.8
958
(1.57)
capita (USS)
(1.55)
(1.55)
1 Health expenditure as percentage of total government expenditure (including externally
financed capital expenditures);
2 Current health expenditure as as percentage of current government expenditure;
3 Capital health expenditures including externally financed expenditures
4 Domestically financed health expenditure.
Source: MSPP (1989a); Lacronique and Mrejen (1990); own calculations
44
GUINEA
MACROECONOMIC EVOLUTION & THE HEALTH SECTOR
ANNEXES
Table 11
Financial Plan, 1990-92
(in millions of US$, GF)
1990
1991
1992 Total $ TotalGF
16.141
17.955
15.378
49.473
0.211
0.100
0.327
0.378
0.429
0.594
0.452
0.839
0.878
1.041
1.368
1.799
10.64
Equipment/cars
Financing
Central Government
Collectivity
Cost recovery
External assistance
8.125
7.377
5.951
1.467
0.5
0.05
3.934
5.913
5.571
1.613
0.58
0.083
3.294
8.79
4.418
3.807
1.775
0.75
0.108
1.174
27.555
17.71
15.33
4.855
1.83
0.242
8.403
Financing Gap
10.19
12.384
11.571
34.144
I. Principal Proposition
Expenditure
Curent expenditure
Salaries
Drugs etc.
Others
Capital expenditure
Construction/renovation
II. Additional Propositions
Expenditure
Current expenditure
Capital expenditure
Financing
27.767
12.341
Central Government
External assistance
1.388
Financing Gap
15.426
1.388
■ • ............
. . . .■ .
... ■
26.379
III. Propositions I and II
Expenditure
Current expenditure
Capital expenditure
Financing
77.241
Central Government
Other domestic financing
External assistance
6.243
2.072
Financing Gap
16.55
60.691
16.718
.
52.524
11.254
41.27
8.403
11.368
4.245
4.409
5.714
60.523
41.155
Source: MSPP (1989a); 1$ = 680 GF (1 October 1990)
45
GUINEA
MACROECONOMIC EVOLUTION & THE HEALTH SECTOR
Figure 1
Organizational Chart of the SEDSP
* Special responsibility under proposed Project
Source: World Bank (1989a)
46
ANNEXES
GUINEA
MACROECONOMIC EVOLUTION & THE HEALTH SECTOR
ANNEXES
Figure 2
Organizational Chart of the MSPP
Source: MSPP (1989a)
47
GUINEA
MACROECONOMIC EVOLUTION & THE HEALTH SECTOR
Figure 3
Structure administrative regionale
prevue par les decrets
003/PRG/SGG/89; 004/PRG/SGG/88 et 008/PRG/SGG/89
Source: FAO (J989)
48
ANNEXES
Position: 1273 (4 views)