Documentof The World Bank FOROFFICIAL USEONLY Report No: 42839-CG PROJECT APPRAISAL DOCUMENT ON A PROPOSED GRANT INTHE AMOUNT OF SDR24.3 MILLION (US$40.0 MILLION EQUIVALENT) TO THE REPUBLIC OF CONGO FOR A CONGO HEALTH SECTOR SERVICES DEVELOPMENT PROJECT May2,2008 Human Development I11 Country Department Central Africa 2 Africa Regional Office This document has a restricted distribution andmay be usedby recipients only inthe performanceof their official duties. Its contents maynot otherwise be disclosedwithout World Bank authorization. CURRENCY EQUIVALENTS (Exchange Rate Effective April 1,2008) CurrencyUnit = XAF XAF414 = US$1 US1.64 = SDR 1 FISCALYEAR January 1 - December 31 ABBREVIATIONS AND ACRONYMS ACTS Artemisinin-based combination therapies AFD FrenchDevelopment Cooperation Agency AfDB African Development Bank AG Auditor General ANC Antenatal Care APL Adaptable ProgramLending ARV Anti Retro-Viral drug AM Acute Respiratory Infections AWP Annual work plan BCC Behavior change communication BEmONC Basic emergency obstetric and neonatal care CAB Cabinet CBA Cost benefit analysis CD Communicable diseases CDMTS Mediumtermexpenditure framework CEmONC Comprehensive obstetric and neonatal care CFA Communautd Financidre Africaine CFAA Country Financial Accountability Assessment CFAF Franc de la CommunautdFinancidreAfricaine CHG Direction Gdndrale de I'Hygidne CHU UniversityReference Hospital CHW Community healthworker CIFA Country Integrated Fiduciary Assessment C-IMCI Community-based Integrated Management of Childhood Illnesses CIPC Country Procurement Issue Paper CNLS National AIDS Council (Conseil National de Lutte contre le SIDA) CNTS National Blood Transfusion Center CNSES (Implemented the ECOM) CODIR Regional hospital community co-management committee COGES First referralhospital community co-management committee COMEG Congolese Company ofEssential Generic Medicines COSA Health center community co-management committee CPR Cadre de Politique de rdinstallation CSI IntegratedHealth Center css Health District (Circo-conscription Socio Sanitaire) DA Designated account DAF Directorate of Administration and Finance DDS Regional Health Directorate (Direction Dipartementale de la Santi) DEP Direction de 1'Etude et de la Planification. 11 .. FOROFFICIAL USE ONLY DFH Department of Family Health DGAF Director General of Administration and Finance DGAP Director General for Administration andPlanning DGAS Assistant Director General for Health DGE Direction Gknkralede 1'Environnement DGPD Direction Gknkrale du Plan et Dkveloppement DGRP Director General o f Resourcesand Planning DGS Director General o f Health DGT Directeur Gkntral du Trisor DHS Demographic and Health Survey DL Disbursement letter DLM Directorate of DiseaseControl DOTS Directly Observed Treatment, short-course (TB) DP Development partners DPHLM Directorate o f Pharmacies, Laboratories and Medicines DPI DirectionduPlanet d'Investissement DPT Diptheria, pertussis, tetanus DRC Direction gknkrale de la Construction DRE Direction rigionale de 1Environnement DRH Directorate o f Human Resources ECOM EnqutteCongolaise aupres des mknages (Congo HouseholdSurvey) EDS Enqudte dkmographique et de santi (DHS) EmONC Emergency Obstetric and NeonatalCare EO1 Expression o f interest EPI ExpandedProgram o f Immunization ESMF Environmentaland Social Management Framework ESMP Environmental and Social Management Plan EU EuropeanUnion FHD Family Health Directorate FM Financial management FS Health facility formation sanitaire) GDP Gross domestic product GNC General Procurement Notice GOC Government of Congo HBV Hepatitis B virus HCV Hepatitis C virus HIV/AIDS Human Immunodeficiency Virus - Acquired Immunodeficiency Syndrome HIPC Heavily IndebtedPoor Countries Initiative HMIS Health Management Information System HNP Health, Nutrition& Population HR Referralhospital (h6pital de rkfkrence) HRH HumanResourcesfor Health HRIS Humanresource information system HSSDP Health sector services development project IA InternalAudit ICB Internationalcompetitive bidding ICR ImplementationCompletionReport IDA InternationalDevelopmentAssociation IEC Information, Education, Communication IFR InterimFinancialReport IGA Income generating activities This document has a restricted distribution and may be used by recipients only in the performance o f their official duties. Its contents may not be otherwise disclosed without World Bank authorization. IGF InspectionGeneral des Finances IGS InspectionGCnerale des Services du Ministere de la Sante IMCI Integrated managemento f childhood illnesses IMF InternationalMonetary Fund I-I-PRSP Interim PovertyReduction Strategy Paper IPP Indigenous people's plan IPT Intermittent preventive treatment ISN InterimStrategy Note JAR Joint annual review JICA Japanese InternationalCooperation Agency lb Live births LBW Low birthweight LCS Least-cost selection LIB Limitedinternational bidding LLINS long-lasting insecticidalnets LNSP NationalLaboratory for BloodTransfusion M&E Monitoring and evaluation MAP Multi-Country HN/AIDS Program MCH Maternal and Child Health MDGs MillenniumDevelopment Goals MEB Marginal excess burden MFEB Ministry o f Finance, Economy and Budget MICS MultipleIndicator Cluster Survey MIS Malaria Indicator Survey MOU Memorandum of Understanding MSASF Ministry o f Health, Social Services and Family Welfare MTEF Medium-TermExpenditure Framework MTR Midterm review NC Central level (Niveau central) NCB National competitive bidding NGO NonGovernmental Organizations N O Nonobjection NPV Net present value NRM National road map OMD MillenniumDevelopment Goals ONG Nongovernmental organization OPiBF Operational policy/Bank financing OR Operations research PAGGEFP Plan d'Action Gouvernemental sur la Reforme de la gestion des PASCOB Project for the Support o f Health SysteminCongo Brazzaville PDO Project Development Objective PEFA Public Expenditure and Financial Accountability PER Public Expenditure Review PFE Pointfocal de l'environnement PFM Procurement and FinancialManagement PIM Program Implementation Manual PMAE Paquet minimum d'activitbs blargies PMTC Preventing mother-to-child transmission (HN) PNDS National Health Development Plan PNLP National Malaria Control Program PNLT National TB Control Program iv PFM Public Financial Management PHC Primary Health Care PHRD Policy and Human Resources Development (Japanese Trust Fund) PIU Project Implementing Unit PLVSS HIV/AIDS control and health project (Projet de Lutte contre le VIH/SZDAet de Santd) PNUD United Nations Development Program POW ProgramOfWork PRCTG Projet duRenforcement des CapacitCs de Transparence et de Gouvernance PREM Poverty Reductionand Economic Management Network I-PRSP Poverty ReductionStrategy Paper PSE Package o f essential health services PSDSS HSSDP (Projet sectoriel de dkveloppement des services de la santk) QCBS Quality and Cost Based Selection RC Community health worker (relais communautaire) RESEN National EducationSystem Network (Rdseau du systPme dducatf national) RHS Human Resource Development SBA Skilled birthattendant SBD StandardBiddingDocument SEP Permanent executive secretary SIL Sector Investment Lending SGS General Secretary o f Health SNDE National Water Distribution (SocieteNationale de Developpement des Eaux) SNE SocieteNationale d'Electricite SNIS National health information system SNPC National Oil Company o f Congo (Socidtd Nationale des Pdtroles du Congo) SOE Statement o fExpenditures SP sss Sulfadoxine-pyrimethamine Single source selection STI Sexually transmitted infections SWAP Sector-Wide Approach TB Tuberculosis TFR Total Fertility Rate TOR Terms o f reference TSS Transitional support strategy TT Tetanus toxoid UN United Nations UNAIDS United Nations Joint Programme on HIV/AIDS UNDB United Nations Development Business UNDP United Nations Development Programme UNESCO United Nations Educational, Scientific and Cultural Organization UNFPA United Nations Fundfor PopulationActivities UNICEF UnitedNations Children's Fund VCT Voluntary counseling and testing (HIV) WB World Bank Vice President: Obiageli KatrynEzekwesili Country Director: Marie-Franqoise Marie-Nelly Country Manager Midou Ibrahima Sector Manager: Lynne Sherburne-Benz Task Team Leader: Khama 0.Rogo V REPUBLICOF CONGO HEALTHSECTOR SERVICES DEVELOPMENT PROJECT CONTENTS Page I STRATEGICCONTEXTANDRATIONALE . 1 A. COUNTRYAND SECTORISSUES .............................................................................................. i B. RATIONALEFOR BANK~VOLVEMENT .................................................................................. 4 C. HIGHER LEVEL OBJECTIVESTO WHICH THE PROJECTCONTRIBUTES ...................................... 5 I1 . PROJECTDESCRIPTION 6 A. LENDING INSTRUMENT .......................................................................................................... 6 B. PROGRAMOBJECTIVE AND PHASES ....................................................................................... 6 C. PROJECT DEVELOPMENT OBJECTIVE AND KEY INDICATORS ................................................... 7 D. PROJECT COMPONENTS ......................................................................................................... 7 E. LESSONS LEARNED AND REFLECTEDINTHE PROJECTDESIGN .............................................. 10 F. ALTERNATIVES CONSIDEREDAND REASONS FOR REJECTION ............................................... 11 I11 . IMPLEMENTATION 11 A. PARTNERSHIPARRANGEMENTS ........................................................................................... 11 B. INSTITUTIONAL .................................................... AND IMPLEMENTATION ARRANGEMENTS 15 C. MONITORING EVALUATIONOFOUTCOMES/RESULTS................................................... AND 17 D. SUSTAINABILITY ................................................................................................................. 18 E. CRITICAL RISKS AND POSSIBLE CONTROVERSIAL ASPECTS.................................................. 20 F. LOAN/CREDIT CONDITIONS AND COVENANTS ...................................................................... 22 IV. APPRAISAL SUMMARY 22 A. ECONOMIC AND FINANCIALANALYSES ............................................................................... 22 B TECHNICAL......................................................................................................................... . 23 C. FIDUCIARY.......................................................................................................................... 24 D. SOCIAL ................................................................................................................................ 26 E. ENVIRONMENT .................................................................................................................... 27 F. SAFEGUARDPOLICIES ......................................................................................................... 27 G. POLICY EXCEPTIONS AND READINESS ................................................................................. 28 vi ANNEX1:COUNTRYAND SECTORORPROGRAMBACKGROUND 29 ANNEX2: MAJOR RELATED PROJECTSFINANCEDBYTHE BANKAND/OR OTHER AGENCIES 39 ANNEX3: RESULTSFRAMEWORK MONITORING AND 44 ANNEX4: DETAILEDPROJECT DESCRIPTION 61 ANNEX5: PROJECTCOSTS 65 ANNEX6: IMPLEMENTATION 66 ARRANGEMENTS ANNEX 7: FINANCIAL MANAGEMENT AND DISBURSEMENTARRANGEMENTS 71 ANNEX8: PROCUREMENT ARRANGEMENTS 89 ANNEX9: ECONOMIC AND FINANCIALANALYSIS 99 ANNEX10: SAFEGUARDPOLICYISSUES 116 ANNEX11:PROJECTPREPARATIONAND SUPERVISION 124 ANNEX12: DOCUMENTS INTHE PROJECTFILE 125 ANNEX13: STATEMENTOFLOANS CREDITS AND 128 ANNEX14: COUNTRYAT A GLANCE 129 ANNEX15: PACKAGE ESSENTIAL OF HEALTH SERVICES (PSE) 131 ANNEX16: MALARIACONGO IN 137 ANNEX17: ROAD MAP FORACCELERATINGTHE REDUCTIONOF MATERNALAND CHILD MORTALITY 140 ANNEX18: HUMAN RESOURCE ASSESSMENT 148 ANNEX19: EMPOWERING COMMUNITIESINCONGO'S HEALTHSERVICESDELIVERYSYSTEM156 ANNEX20: PRIORITYAREASFORWB SUPPORT AND IMPLEMENTATIONPLAN 160 ANNEX21: NATIONAL HEALTHPOLICYLETTER 167 ANNEX22: MAP 170 vii REPUBLIC OF CONGO HEALTHSECTOR SERVICES DEVELOPMENTPROJECT PROJECT APPRAISAL DOCUMENT AFRICA AFTH3 Date: May 2,2008 Team Leader: Khama OderaRogo Country Director: M-F.Marie-Nelly Sectors: Health(100%) Sector Manager: Lynne Sherburne-Benz Themes: Health system performance (P);Child Project ID: P106851 health(S);Population and reproductive health Lending Instrument: Sector Investment (S);Other communicable diseases (S) andMaintenance(SIM) Grant Environmental screening category: B [ ] Loan [ ] Credit [XI Grant [ ] Guarantee [ ] Other: For Loans/Credits/Others: Total Bankfinancing (US$m): 40.00 ProPosedterms: FinancingPlan(US$m) Source Local Foreign Total BORROWERRECIPIENT 0.00 0.00 0.00 IDA Grant 12.40 27.60 40.00 Total: 12.40 27.60 40.00 Borrower:Republic of Congo ResponsibleAgency: Ministerede la SantC, des Affaires Sociales et de la Famille Directeur General, B.P. 545, Brazzaville, RCpubliquedu Congo Phone: (242) 678 67 38, Fax: 242 83 68 02, Email: actionsocialecongo@yahoo.fr Projectimplementationperiod: Start: October 2008 End:June 2012 Expectedeffectivenessdate: September 30,2008 Expectedclosing date: May 29,20 12 Doesthe project depart from the CAS incontent or other significant respects? Re$ PADA.3 [ ]Yes [XINO Doesthe project require any exceptions from Bankpolicies? Re$ PADD.7 [ ]Yes [ x ] N o Havethese beenapprovedby Bankmanagement? [ ]Yes [ x ] N o I s approval for any policy exception sought from the Board? [ ]Yes [ x ] N o ... Vlll Does the project include any critical risks rated "substantial" or "high"? Ref: PAD C.5 [x ]Yes []No Does the project meet the Regional criteria for readiness for implementation? Ref: PAD D.7 [x ]Yes []No Project development objective Ref: PAD B.2, TechnicalAnnex 3 The development objective o fthe project is to support thestrengthening of the health system in order to effectively combat the major communicablediseases and improve access to quality servicesfor women, children and other vulnerablegroups. Project description[one-sentence summary of each component] Ref: PAD B.3.a, Technical Annex 4 Component1:Strengtheningleadershipcapacitiesinmanaginga functioningand decentralizedhealthsystem. This component will strengthen management andleadership capacities at all levels withinthe government's decentralization program, includingmonitoring andevaluation. Component2: Developmentandimplementationof an efficient and effectivesystem for managinghumanresourcesfor health(HRH). This component will support establishment of a separateHRHDirectorate inthe central Ministrywith specific HRmanagement functions and the technical capacity to create position descriptions and build a repository o ftechnical fields andprofessions employed throughout the healthsector as well as designand set upa medium- term development planfor HRH. Component3: Rehabilitationand equipmentofhealthfacilities. Thiswill support the mapping and priority andnonnshtandards-setting exercise and assist the GOC, inensuring rational expenditure o ftheir resources on phased rehabilitationo f facilities, with special attention to the primary care level as well as establishingnational equipment standards and norms and rationalphasedprocurements plan. Component4: Improvementof access to a packageof quality essentialhealthservices (PSE). This component will support provisionofa Package o fEssential Services (PSE) to all Congolese, strengthen the procurement and efficient management o f essential medicines and medical supplies building on the framework already establishedby the EUunder PASCOB (COMEG), empower communities intheir roles as co-managers o f health services addressing harmfultraditional andsocial practices throughcommunication for behaviorchange (BCC) and promote equitable access to quality health services for all. Which safeguard policies are triggered, ifany? Ref: PAD 0.6, TechnicalAnnex 10 The project has triggered safeguard policies OP/BP4.0 1(Environmental Assessment), OP/BP4.12 (Involuntary Resettlement) and OPPB 4.10 (Indigenous Peoples). Significant, non-standard conditions, if any, for: N/A Ref: PAD C.7 Boardpresentation: May 29,2008 Loadcredit effectiveness: September 30,2008 Covenants applicable to project implementation: Standard ix I. STRATEGICCONTEXTANDRATIONALE A. Country and sector issues 1. The Republic o f Congo is recovering from the devastation o f one decade o f civil wars that left the majority o f its citizens destitute and its infrastructure in shambles. The population i s now clamoring for the peace dividends and the government has responded by taking specific measures to enhance macroeconomic stability and expand access to affordable, quality social services. IDA i s supporting Congo along this path through several projects, focusing on Governance, Emergency and Demobilization, Basic Education, Agriculture and Rural Development and HIV/AIDS. The health sector was severely weakened by the civil war and has recently risen to the top o fthe country's reform agenda. 2. Congo's social indicators may not be the worst in Africa but they are rather poor compared to countries with comparable income. Although the economic situation inthe country has recently improved and Congo is now classified as a lower-middle-income country, 50% of the population still lives in poverty, and the country remains IDA-eligible. The relatively high per capita income disguises wide disparities in wealth across the country. According to recent World Bank data, even the current growth rate o f 5 percent will not be sufficient to lift a quarter o f the population out o fpoverty by 2015. 3. Rapid population growth and deteriorating health indicators: Congo's population o f 3.9 million i s growing at an annual rate o f 2.8%, and the estimated Total Fertility Rate (TFR) o f 6.3 i s one of the highest in Sub-Saharan Africa. The average life expectancy i s only 49 years, with no significant increases for both sexes since 1984. This is partly due to the highdisease burdenin Congo that i s largely due to preventable causes. Sixty to 90 percent o f the morbidity inCongo is due to infectious diseases and maternal and child illnesses. In 2006, 55 percent o f out-patient consultations in public hospitals in Congo were due to malaria alone. Most o f the tropical communicable diseases such as Schistosomiasis, Trypanosomiasis, Onchocerciasis, Leprosy and BuruliUlcer are now resurgent inCongo. New infectious diseases have also emerged, the most recent being Ebola and other hemorrhagic fevers. For the first time in history, Cholera i s now endemic in Congo, predominantly in urban areas. The infant mortality rate o f 75 per 1000 live births and maternal mortality ratio o f 781per 100,000 live births are unacceptable for a country with a relatively small population and significant resources. On the positive side, the HIV/AIDS prevalence rate o f around 4.3% has remained stagnant for some years but the TB incidence i s rising. Overall, the health status of the Congolese has been deteriorating, and if present trends continue, the country's MillenniumDevelopment Goals (MDGs) are not likely to be achieved. (See health indictors and MDGtrends inAnnex 1). 4. Health systems are broken and unregulated: It i s impossible for any African country to achieve the MDGs without viable health systems, and Congo i s no exception. The weaknesses in Congo's health system and the poor outcomes are adequately diagnosed in the Plan National de Develuppement Sanitaire (PNDS) that was prepared with support from technical agencies and local and external partners. The PNDS - while underlining the continued dominance o f communicable diseases in Congo and the resurgence o f Malaria, TB and Cholera as endemic problems - also highlights the following key problems: high levels o f malnutrition, gaps in leadership and organization o f the sector at all levels in addition to absence o f accountability, 1 inappropriate management o f human resources; poor quality o f services (including recurrent stock outs o f drugs and supplies), poor infrastructure and lack o f basic maintenance; weak monitoring and evaluation and no feedback loops, and very weak regional and district health systems without community participation. Paradoxically, the DHS (2005) found that the use of health services in Congo was relatively high. For example, the proportion o f women delivering in the presence of skilled birth attendants was over 80%, indicating that the high maternal mortality could be indicative o f poor quality o f services. The skewed distribution o f facilities is another important factor contributingto poor health outcomes in Congo. A recent study showed that out o f the 1712 public and private health facilities in Congo in 2005, about 49% were located in urban areas; 35% in rural areas and 16% in sub-centers, revealing that the bulk o f facilities are in urban areas. In general, public facilities lacked materials and technical equipment, and 7.6% o f them were closed due to dilapidated infrastructure and lack o f equipment and personnel. The study further confirmed that despite the significant presence in curative services, the private sector received little attention and was neither organized nor appropriately regulated. 5. Civil war is not the only factor: Multiple factors account for good health, and the adversity and multiplicity in these factors has engendered the worsening health status of Congolese. The civil war destroyed Congo's fragile health infrastructure and public health services recovery has been slow and painful. The ravages o f the war are important considerations butpoverty and inequityare equally critical factors for the slow pace o frecovery andpoor health indicators. The contrast between substantial wealth and very poor social conditions o f Congolese i s stark. Furthermore, widespread poverty and destitution i s closely linked to food insecurity. This explains why malnutrition i s the major underlyingfactor inchild mortality inCongo. Infant mortality has not dropped since 1984, the under- five mortality rate hovers well above 100 per 1000 live births and the relatively high vaccination rates for key immunizable diseases do not appear to have had a significant impact on reducing child mortality (DHS, 2005). 6. Congo's strategic approach (PNDS 2007-2011): The 1990s were lost to the civil war, and the Congolese were unable to implement the 1992-1996 PNDS. The end o f the war enabled the country to develop an emergency post-conflict plan (PIPC) of 2000-2002 that allowed limited emergency investments in the health sector. The period also revealed major systemic problems which rendered the sector non-responsive to the basic needs o f the general population, especially the most vulnerable. These problems included: 0 Lack o f coherent legal and administrative linkages and guidelines for all levels o f the health system, including centralization o f decision making and duplication o f responsibilities; 0 Lack o f strategic priorities and interventions, leading to poor resource allocation and exacerbating geographical and social inequalities in access to services; 0 Weak planning capacity and accountability in the sector, including fiduciary and human resources for the health sector (HRH); 2 0 Poor community participation in management o f health care services, leading to low utilization; 0 Failure to engage traditional andprivate health care providers; 0 Weak health information system that renders results and impact difficult to measure; Weak coordination o f stakeholders, including external partners and lack of intersectoralcollaboration. 7. Consequently, the government, in collaboration with national stakeholders and its external partners, embarked on the preparation o f a new comprehensive PNDS for the period 2007 - 2011. The PNDS was adopted in 2007 and seeks to improve the health status of the population in general and that o f women, children and other vulnerable/marginalized groups in particular. The plan seeks to strengthen Primary Health Care through the district health system and community (Bamako initiative) approach. 8. The PNDS acknowledges that previous efforts failed due weak governance o f the sector and poor coordination of the multiplepiecemeal interventions that were also poorly monitored. It boldly recommends a revision in approach, focusing on strengthening the performance o f the health systems at all levels and developing integrated health programs to deliver a well defined essential health package (PSE). This would be done within the decentralized approach already adopted for the public sector and by creating an enabling environment for private sector participation. It would require revision o f the institutional framework to enhance communication and accountability at the central level and boost stewardship capacity for policy formulation, planning, coordination, support o fthe regional and district healthmanagement teams. 9. The plan also coincides with the President's vision for a new hope for Congo (Nouvelle Espkrance) and i s in line with Congo's poverty reduction program (I-PRSP) to accelerate the attainment o f the MDGs, focusing on reduction of maternal and under-five mortality, intensifyingmalaria control and the fight against HIV/AIDS andtuberculosis, and strengthening health systems to provide appropriate curative, preventive and promotional interventions that would reduce the high disease burden. Harnessing o f Congo's enormous potential requires effective stewardship by a revamped Ministry o f Health (MSASF), including financial and technical support from partners. 10. Evident commitment to reforms: The Congolese acknowledge that attainment o f the MDGs requires overcoming many challenges and they are asking for assistance to achieve this. The specific challenges for the health sector are: (1) the promotion o f governance, as well as macroeconomic and institutional frameworks conducive to private sector development; (2) investment inthe rebuildingo f infrastructure and human capital to improve the competitiveness o f the economy, social security coverage for the poor, and the quality o f the education system andhealth system; and (3) the promotion o f strong, sustainable growth, and equitably distributed. It is also clear that poverty reduction requires not only high growth rates but also budgets targeted at pro-poor policies. 3 11. The I-PRSP thus appropriately focuses on five strategic areas: (i) consolidation of peace, and improvementof security and good governance, (ii) promoting economic growth and a stable macroeconomic framework, (iii)improving people's access to basic social services, (iv) improving the social environment, and, (v)strengtheningthe fight against HIV/AIDS. 12. The 2006-2010 PNDS builds on the I-PRSP and signifies the Government of Congo's (GOC's) strong political commitment to reforming the health sector by improving the performance of the health systems. In that commitment the government acknowledges that substantial funds will be neededto support the reforms and to reduce the burden of morbidity andmortality. The GOC further acknowledges that the current Public expenditureson health (of the order o f US$69.8million in 2005) are relatively low. In2005, Congo spent only 5.4% o f its public expenditure on health, which i s lower than neighboring countries. It i s estimated that six hundred and fifty million USD (US$650.0million) would be neededto support the PNDS. This in not an impossible target for Congo as the surge in oil revenues has openedup an excellent opportunity to reduce poverty and improve living standards. Public spending on health has increased significantly inrecent years although the percentage o f the national budget allocated to health remains far below the Abuja commitment o f 15% o f the national budget. The health and HIV/AIDS's share of the national budget amounted to US$132.9 million, representing about 6.0%, in 2007. This rose to 7.3% (US$152.5 million) in 2008, and i s projected to increase to 11.4% (US$248.4 million) in2009. 13. Another sign o f strong continued commitment was the attainment the healthrelated HPIC triggers in March 2006, specifically establishing a transparent procurement mechanism for generic drugs. This should be seen in the context o f GOC's efforts to decentralize decision- making in the management of public resources in collaboration with the beneficiaries. The decentralization policy facilitates transfer o f competencies to local authorities to improve management o f primary and referral services. Effective partnershipi s being developed between government and civil society. NGOs are expected to play a significant role in the democratization process and delivery of services resulting in more decentralized decision- making and strong community participation. 14. Finally, the government has shown clear inclinations towards reducing household expenditure on health care through recent decrees that abolished payment for maternal and child services, HIV/AIDS testing and treatment including ARVs and opportunistic infections and Malaria prevention and care such as long-lasting insecticide-treated bed nets (LLINs) and chemotherapy. These measures should enhance access to the PSE for poor and vulnerable groups. B. Rationale for Bank involvement 15. Encouraging progressive client initiatives and unique opportunities: As stated above, the GOC has initiated several activities that are indicative o f strong commitment to reforms. They include: (a) Strategic choices made by the government in its sector policy and strategy documents that emphasize strengthening leadership, management, and coordination at all levels o f a decentralized healthcare system, (b) determination to rationalize and strengthen a comprehensive health sector human resource management system, (c) a strategic option to rationalize infrastructure rehabilitation o f health facilities severely damaged by the civil war and 4 affected by years o f sector under-funding linking such work to delivery of an essential health package, while giving high priority to prevention and health promotion, and (d) initiation of the Transparency and Governance Capacity BuildingProject that has been supporting key elements o f public sector reforms. Key actions being undertaken include: improving predictability o f oil sector revenues and enhanced transparency in the management o f the national oil company (SNPC), enhancing levels of accountability inpublic management through the establishment of effective anti-corruption structures, improving effectiveness in budget management through streamlined budget procedures, strengthened public investment planning and implementation systems as well as a reformed public procurement system and a rationalizedpublic sector wage bill management. 16. Requestfor IDA support: The PNDS and the five-year Program of Work (POW) being developed have the unequivocal support from both internal and external partners. The intensive consultative andjoint designprocess bodes well for broad-based ownership and partnerships and inclusion o f the private sector, which i s new in Congo. There i s also a strong demand from the health sector and other partners for technical and policy support from the Bank. IDA'Sfinancial support has a reassuring effect and has leveraged additional support from partners who would otherwise not support the sector. 17. IDA's comparative advantage and compliance with current strategies: Congo does not have a plethora o f donors and the GOC and other partners recognize the Bank's considerable experience implementing development assistance in Congo. They are seeking IDA'Sleadership in stimulating and coordinating dialogue with authorities and stakeholders on sector reforms in health and other areas. The Bank has been a strong supporter of comprehensive health sector approaches (SWAps) in many African countries with encouraging results. The proposed project i s complementary to, and builds on the lessons from the HIV/AIDS and Health M A P project. It also recognizes the need to harness support from the other sectors that are already receivingIDA support in Congo such as Governance, Urban and Rural development, and Agriculture. Finally, the proposed emphasis on strengthening health systems is in conformity with the World Bank's new HNP strategy andcomplies with the Africa Action Plan's main objective o f staying engaged inconflict-affected countries andbuildingnationalcapacities for sustainable development. C. Higher level objectives to which the project contributes 18. Accelerating progress towards the MDGs: At the current pace o f change and social development, Congo i s unlikely to meet the health-related MDGs or any other international targets relating to health. The project therefore deliberately focuses on strengthening delivery o f maternal and child services and combating malnutrition and communicable diseases, especially Malaria. In addition, the project will build on the achievements of the HIV/AIDS program to reinforce and integrate the health sector, recognizing that multi-sectoral actions are needed to accelerate progress towards attainment o f MDGs 1 (eradicate extreme poverty and hunger), 4 (reduce child mortality), 5 (improve maternal health) and 6 (combat HIV/AIDS, malaria and other major diseases). 19. Goodgovernance and equity: Stronger health systems should result inbetter stewardship and improved governance o f the sector and beyond. The health sector program i s the first attempt at streamlining sector governance and accountability in Congo and should provide a template for 5 the country, working closely with the Bank-supported Governance Project. The focus on PHC and the design of the PSE as both a rationing and targeting strategy for health interventions provides an opportunity for the efficient and equitable utilization o f health resources. 20. Poverty alleviation: I11health and poverty are closely intertwined. As observed in the I- PRSP, poverty creates ill-health because it forces people to live inenvironments that make them sick, without decent shelter, clean water or adequate sanitation. I11 health creates poverty by reducing people's capacity to create wealth, while spending meager earnings on treatment and care. Strengthening PHC and ensuringaccess to the PSE to every Congolese i s at the core o f the PNDS and therefore o f the 5 year POW. The PSE deliberately targets the most important health problems in Congo that disproportionately afflict the poor and should lead to reduction o f the disease burden. 21. Relevance to the ISN and I-PRSP objectives: The InterimStrategy Note (ISN, 2007) has two major themes - improving governance and strengthening access to service delivery for the poor. Together with the I-I-PRSP, the I S N identified the need for increased attention to and investment inthe health sector. 11. PROJECTDESCRIPTION A. Lendinginstrument 22. A Sector Investment andMaintenance(SIM) Grant is the proposedlending instrumentto support selected aspects o f the MSASF's overall 5-Year POW for a comprehensive health sector development program. The US$40 grant from IDA shall supplement Congo's own health budget while complimenting the contributions o f the EU, AFD and other potential donors towards the overall program. 23. A comprehensive health systems development and service delivery approach, to which the IDA support will contribute, is favored for Congo as the country is now in a stable post- conflict situation. The entire health sector i s underperforming and i s in need o f a significant overhaul to enhance efficiency and effectiveness. In general, a sector wide approach (SWAp) embraces three central and recurrent themes; sector-wide, ownership and coordination. Although these themes provide the basis for developing the sector program in Congo to which this project will contribute, the country is not yet ready for a mature SWAP due to the weak fiduciary systems. The country already has some elements o f a SWAp, including the government's willingness to address both strategic and management issues in the sector, a coherent sector strategy (PNDS, a stable partnership and commitment o f key local and external stakeholders (MoU); and a collaborative program o f work (POW). This project intends to build on these elements and work with other partners to move Congo towards eventually to a SWAp. B. ProgramobjectiveandPhases 24. The sector reforms and development proposedby the PNDS, and which this project will support include: (a) building sector leadership capabilities for improved partnership coordination, monitoring and evaluation, and management of the decentralized healthcare system at all levels; (b) institutingan efficient perfonnance-based human resource management system; 6 (c) rehabilitating health facilities, particularly at primary and first referral levels to improve access and quality o f care; and (d) defining and streamlining priority curative, preventive, and promotional interventions, integrating 12 ongoing vertical programs in both public and private healthservices. C. Projectdevelopmentobjectiveandkey indicators 25. The development objective o f the project is to support the strengthening of the health system in order to effectively combat the major communicable diseases and improve access to quality servicesfor women, children and other vulnerable groups. 26. Within the comprehensive sector development program ofthe PNDS, the IDA supported project will focus primarily on strengthening sector stewardship, fiduciary systems and monitoring and evaluation (Component 1); human resources (Component 2); Infrastructure assessment, mapping and comprehensive rehabilitation plan, including limited construction (Component 3) and, delivery of Package of Essential Services (PSE), with emphasis on Malaria HIV/AIDS and MCH, pharmaceuticals management, community participatiodindigenous peoples and equity (Component 4). 27. Key indicators: The principal outputs expected are: a) enhanced capacity o f MSASF for policy development and stewardship; b) strengthened capacity o f MSASF for planning, health financing, procurement and effective monitoring and evaluation leading to rational and equitable use o f resources, and reliable pharmaceutical and supplies logistics; c) strengthened Departmental HealthManagement systems for planning, budgetingand delivery o f quality health services; d) Improved management o f human resources to address training, recruitment, motivation and retention o f skilled personnel, working closely with other ministries; e) improved access to quality health care and a package o f essential services for the poor and vulnerable populations; and f) active community participation in prevention and the delivery o f essential health interventions. 28. It is expected that improvement on the Project Outcome Indicators will contribute to reduced child mortality (MDG4), reduced maternal mortality (MDG5) and expanded malaria control (MDG6). Progress on these indicators will reflect improved provision of curative, preventive and promotive services and tools (e.g. insecticide treated bednets - ITNs), community participation and effective communication for behavior change. Lack o f progress will trigger an assessment o f which o f the underlying system elements (leadership, human resources, supply chain management, community participation, etc.) i s or are lagging to permit strategic re- direction o f activities as needed. D. ProjectComponents 29. Component 1: Strengtheningleadership capacities in managing a functioning and decentralized health system. This component will strengthen management and leadership capacities at all levels within the government's decentralization program. The process will involve strengthening capacities in planning and managing sector operations, working within a 7 framework of partnership and stakeholder coordination under the following three sub- components. 30. Subcomponent 1.1: Capacity building for leadership and effective manaaement of a decentralized health system. Situation analyses will be done and the recommendations used to inform appropriate institutional reforms in the sector through creation o f a new organogram. Specific attention will be placed on capacity building for planning and management o f the sector at all levels as well as strengthening the coordination o f all stakeholders (communities, NGOs, private sector and external partners). 31. Subcomponent 1.2: Strenathenina fiduciaw svstems. Thorough assessment o f the current financial and procurement systems were done and the gaps identified and discussed with the stakeholders. Additional analytical work, including National Health Accounts i s being undertaken to lay grounds for an MTEF. The project will use this information to strengthen operational capacities for transparent financial management and procurement. Systems will be put inplace to document resource usages at all levels, includinggovernment, donor and private sector, and for equitable, efficient and sustainable allocation. Both internal and external audit functions will be developed. Studies would be conducted to identify an appropriate health sector financing system and policy for the Congo by drawing upon ongoing experiences with cost sharing and community "mutuelles." MSASF procurement capabilities at the central, regional and district levels will also be strengthened. 32. Subcomponent 1.3: Strengtheninn Monitorina and Evaluation. Through this subcomponent, a monitoring and evaluation system strategy and plan for the sector will be developedand implementedto improve the availability and use o f needed information by actors at multiple levels o f the system. The strategy and plan will address the basic components o f an efficient and effective system, including routinely reported health management information, sentinel site surveillance activities, periodic assessments and health system operations research. An operational plan to refine and support the scale-up o f a national health management information system (for routinely reported information) will be developed and implemented, buildingon work that has begunon this topic. Epidemiologicsurveillance will be strengthened, for epidemic-prone diseases and for supporting sentinel sites activities for tracking illnesses, insecticide-resistance, treatment efficacy and pharmacovigilance, among others. Appropriate planning for periodic household and facility-based survey assessments will be ensured, and a health system operational research plan will be developed and implemented. Finally, support will beprovided for periodic updates o f service delivery maps. 33. Component2: Developmentand implementationof an efficientand effective system for managing health sector human resources (HRH). A baseline HRH database currently beingdeveloped will be usedto establish a separate HRHDirectorate inthe centralMinistrywith specific HR management functions and the technical capacity to create position descriptions and builda repository o ftechnical fields andprofessions employedthroughout the health sector. The Directorate will also organize a multi-sector consultative framework for working with Ministries o f Education that are responsible for training medical and paramedical staff to serve in the MSASF. Under this component, incentives will be created to motivate staff in all areas (e.g. equitable in-service and longer-term training programs, the institution o f more transparent 8 appointments, and performance-based assignment and promotion systems based on merit and required competencies). A medium-term development plan for HRHwill be designed and set up. 34. Component 3: Rehabilitation and equipment of health facilities. An ongoing inventory o f the state o f health facilities will be used as input to design how to upgrade facilities, giving priority to the primary healthcare facilities and referral services. IDA will support the mapping and priority and norms/standards-setting exercise and will assist the GOC in ensuring rational expenditureo f their resources on phasedrehabilitation o f facilities, with special attention to the primary care level. 35. Subcomponent 1.1 : Infrastructure rehabilitation, maintenance and construction. Based on the report of the ongoing inventory, IDA will support the adoption o f a rational comprehensive infrastructure rehabilitation plan and establishment o f a standardized regular maintenance calendar for buildings and equipment. While the GOC and other partners will finance the works, the focus will be placed on renovation o f existing facilities and new construction undertaken only in exceptional cases, based on agreed standards and norms (prototypes). 36. Subcomponent 1.2: Euuiument standardization and maintenance. A full evaluation o f the equipment situation in Congo will be undertaken with IDA support and the information will be used to establish national equipment standards and norms and rational, phased procurement plans. The GOC and other partners will provide the resources for setting up Maintenance workshops andto train bio-engineers to cover every region inthe country. 37. Component 4: Improvement of access to a package of quality essential health services. This component will comprise four subcomponents and will receive the bulk o f IDA resources. 38. Subcomponent 4.1: Define and provide a Package of Essential Services. The PSE has already been defined (Annex 15) to include services for children (IMCI), mothers (Road map, Annex 17), adolescents, and to combat major communicable (Malaria, Annex 16) and non- communicable diseases. Maternal and child health outcomes and malaria will receive special attention. Norms, treatment protocols and service organization will be clearly defined and used for training of staff at all levels. 39. Subcomponent 4.2: Strengthen the urocurement and efficient management of essential medicines and medical suuplies buildingon the framework already established by the EUunder the Project for the Support of Health SysteminCongo Brazzaville (PASCOB-(COMEG). Operational capacity o f COMEG will be strengthened inorder to undertake the expanded role o fprocurement o f all pharmaceuticals and supplies according to the financing modalities in the agreement already signed between the Bank, EU and GOC. The D P H L M will be strengthened and new structures created to collaborate with the COMEG in monitoring pharmaceuticals supplies and stocks management. The DPHLM will regulate and supervise private chemists and laboratory institutions, setting and enforcing quality and standards at all levels. Quality control procedures will be established under this subcomponent and qualified staff at the regional healthdirectorates (DDS) will be trained to enforce them. 9 40. Subcomponent 4.3: Emuower communities in their roles as co-managers o f health services. This will be a two way process with both MSASF (supply side) and community (demand side) perspectives. It will entail building o f professional capacity within the MSASF and decentralized levels to coordinate government-community partnerships and strengthen community participation in the management and delivery o f heath services and enhancing effective synergy between PSE and other determinants o f health (water, environmental sanitation, vector management). Community knowledge, participation and support will be strengthened to address maternal and child health and related reproductive health issues. It will also build capacity o f communities to utilize and demand quality services while participating in the management o f health facilities and addressing harmful traditional and social practices through communication for behavior change. 41. Subcomponent 4.4: Promote equitable access to qualitv health services for all. Activities will include an analysis o f constraints to accessing services among the most vulnerable and poor segments of the population (including the pygmies), and the establishment o f measures to support basic needs o f the poor. E. Lessons learned and reflected inthe project design 42. Overarching lessonsfrom Congo. The recent ICR for the Economic Recovery Operation project emphasized that failure to achieve improvement in public investment programming was partly due to the long lead time required to implement major institutional reforms and over- reliance on champions, rather than a broad-based ownership process. Technical assistance was unlikely to be effective in the absence of adequate government arrangements to coordinate the reforms. Close supervision was important for any post conflict country with weak accountability mechanisms. These lessons are also echoed in the MTR report for the on going IDA supported M A P project. The report emphasized that: (a) systemic sector bottlenecks cannot be addressed through a disease focused approach, (b) donor harmonization and the `three-ones' concept i s essential for success andjoint planning and reviews are feasible in Congo, (c) fiduciary risks can be effectively mitigated with appropriate support supervision and capacity building, and (d) a multi-sectoral approach i s feasible and can bring the needed synergy to successfully address epidemics. 43. Lessons from Congo Health Sector. Important lessons from Congo health sector are that (a) individual donor support has been single disease-focused with limited impact on systemic problems o f access and quality; (b) past infrastructure development paid little attention to staffing requirements,disease burdenneeds, equipment, supplies and population distribution; (c) community driven initiatives capable o f significantly improving promotional, preventive and curative care have not been effectively structured or given priority; and (d) failure to address sector organization and management problems in direct investment projects by donors, including IDA, constrained policy dialogue and technical support needed for sustainable sector development. 44. Lessons from comprehensive health sector reforms: These lessons are important as Congo embraces comprehensive reforms and moves towards a SWAp. The Bank has experience with sector wide reforms inseveral countries and regardsthem as integral to its strategy inAfrica 10 as well as the appropriate next step for more effective aid management and health sector development. The lessons in such reforms confirm several potential benefits: (a) expanding inputs alone does not solve the problems, (b) money should be spent on priorities set by the country, not external agencies; (c) aid i s more efficiently managed through the country's existing structures, with only one set o f monitoring and accounting mechanisms; and (d) for poorer countries with many donors contributing to poverty alleviation in the health sector, the effectiveness o f this aid can be dramatically improved through a collaborative and comprehensive approach. 45. Yet sector wide approaches can also have weaknesses. The negotiations may fail; parts of the sector are sometimes excluded from the sector programs; or spending on unproductive areas may continue or even increase. Similarly, once governments are in control o f donors' resources, they may decide to reduce fundingto programs such as malaria andHIV/AIDSandTB andother programs likely to benefit a large proportion o fthe population. F. Alternativesconsideredand reasonsfor rejection 46. `No project' alternative: With IDA'Sacceptance o f the request for support to health sector reforms and accelerated attainment o f the MDGs through its financial and analytical contributions, the "no project" alternative is not viable. IDA i s already supporting the fight against the AIDS epidemic through a M A P project and its MTR confirmed the urgent need for comprehensive sector reforms. The GOC has worked closely with other development partners to prepare the PNDS and define the PSE. The implementation o f the project within the larger framework o f the PNDS and an integrated work program provides a unique opportunity for the Bank to participate in a collaborative effort aimed at improving health outcomes for women, children andvulnerable populations inCongo. 47. Lending instrument: An Adaptable Program Lending (APL) was also entertained but was deemed inappropriate, given the broader macroeconomic environment, status o f the sector andthe extent o f sectoral reforms required.An InvestmentGrant was therefore proposed. 111. IMPLEMENTATION A. Partnershiparrangements 48. Congo does not have many external partners, especially in the health sector. All partners supporting the comprehensive program have agreed to work under the leadership o f the GOC and a first draft o f a Memorandum of Understanding among all the partners has been prepared and i s expected to be concluded early during the implementation o f this operation. They include the European Union, French Agency for International Development (AFD) and the UNagencies (WHO, UNICEF, UNAIDS, UNFPA and UNDP). The MOU signifies the commitment o f the partners to support the common program of work led and implementedby the GOC. It refers to the overall resource envelope that includes GOC budget, financing arrangements, coordination and monitoring arrangements including joint annual reviews and a code o f conduct for partners. 11 Other donors, such as USAID, South Africa, Italy, Cuba and China are equally supportive o f a coordinated approach. 12 e E 0 s W cl I .a E L, * 0 Y 0 0 zm Q) 4 3 3 Q) : 0 Y m 3 .I c, P a .I Y L, W L, Y E L, .. rl -I Q) 3 - m 3 >`I 3 3 >`I N e e . . . e 2 0 N c) a 3 c 3 49. The PNDS cost was estimated at US$650 million for investment and non-wage recurrent costs. The GOC allocated US$146.7 million in the 2008 budget to the health sector (including salaries), an increase o f 1.2% over the previous year. Apart from IDA, other external donors that have committed to support the sector over the next five years include the EU, AFD and the UN agencies (see Table 1). Selected studies are beingundertakenby the GOC, with technical support from the partners, to inform the process. This has been an important confidence buildingstep and i s already providing vital information on institutional arrangements, financing, procurement, infrastructure, human resources (including training schools) and Safeguards. This information I also provides some baseline data, used for realistic planning and linking resource allocation to outcomes. B. Institutionalandimplementationarrangements 50. The project will be implemented within the MSASF organizational set up with reorganized and strengthened units and not through separate Project Implementation Units. The newly appointedGeneral Secretary o f MSASF (SGS), the Director General o f Health (DGS) and the Director General Administration and Finance (DGAF) will have overall responsibility for program implementation (including this project) including the inputs, outputs and quality assurance. They will be supportedby an effective reorganized senior staff cadres (technical and administrative) and report directly to the Minister o f Health (MSASF). As shown inAnnex 6, a detailed revised `governance' structure has beenadopted andi s based on the report prepared by a WHO consultant at the request o f MSASF. The detailed structure creates a new position o f Secretary General that will coordinate technical and administrative arms, ledby the two Director Generals. The creation o f the two directorates separates technical and administrative responsibilities while emphasizing the need for close collaboration to be ensured by the SGS. It also provides an opportunity for appointment o f persons with appropriate qualifications for the various positions. The Ministerial level Comitt de Pilotage (coordination et gestion du secteur de la Santt), Comit6 Technique des services de sante and Comitt de ressource et planijkation chaired by respective Director Generals, have also been established to enhance coordination and regular consultations among senior staff. Clear terms o f reference have been prepared for the committees. They will hold regular scheduled meetingsand minutes will be recorded for follow- up actions. On the advisory side, there will be the Groupe de Dtveloppement du secteur de la santt consisting o f external partners and senior government officials (including Finance, Planning, Education, Agriculture and other key ministries) with sub-groups on selected key topics. 5 1. Although all units inthe central and regional services o f MSASF would be strengthened, special reorganization and capacity building work i s planned for the MSASF departments responsible for Planning and Finance (DEP and DAF) and for human resource development. This is in response to the clear risks identified in the procurement and financial management capacity assessments undertakenby IDA. Due to weak systems and capacities, the large amount o f hnds involved in the program and the challenges o f accountability, effective financial management and internal control will be a priority. To promote timely implementation, long- term technical assistance in the key areas o f financial management and procurement i s being implemented. Procurement o f goods, works and services will be the responsibility o f the Director 15 of the Procurement Unit of MSASF, working closely with the internationally recruited Procurement Adviser, the Director o f Finance and Director of Planning. The Director o f Administration and Finance will be responsible for all financial management and accounting matters inthe Ministry. Table2: Managementand CoordinationOrgansfor the HealthSector Organ Terms of Reference Membership Health Sector Monthly reviewofprogressinproject Management implementation Chair: Ministerof Health and Reviewprogress on ongoingprogram Members:SG, DGS, DGAF Coordination activities Secretary:Advisor to the Minister Committee Monitor donor-funded interventions Health Sector Chair: Minister ofHealth Management Members:SG, DGS, DGAF, Ministries and Quarterlyreviewof the public healthissues o f Finance, Planning, Public Affairs, Coordination and intersectoralcollaboration Education,Agriculture, Water, Committee Municipalities andother keynational PLUS Secretary:Cabinet duMinistre Chair: DGS Technical Weekly meetingsto reviewtechnicalissues Members:DGA, DGAF, DEP, HR, Committee inProjectandMSASF Representativesof Privatesector and TraditionalPractitionersetc. Secretary:DGA Administration Weekly meetingsfor informationexchange Chair:DGAF and Finance anddiscussionsof humanresources Members:DGS, DGSA andall Directors Committee and finance management issues inMSASF Planningfor project, programandMSASF Secretary :DEP Quarterlymeetingson issues inproject, Chair: MinisterofHealth Health Sector programandMSASF(exchangeof Members:SG, DGS, DGAF, other Development information, discuss progress, provideadvice Directors,National andInternational Committee andadvocate) partners, Establishappropriatesub-committees Secretary:DirectorofCooperation and Communication, MSASF Six monthlysupport supervision and missions Review of the Annualjoint reviews ofproject, programand Chair: Ministero fHealth Health Sector MSASFperformance Members:All stakeholders Discussion andagreement ofAnnual Work Secretary: SG Plan andBudget 52. At present, the MSASF operates a fairly centralized management system, with the Central and Regional Hospitals enjoying significant levels o f autonomy. The concept o f Departmental and District Health Management Teams i s present in Congo but i s not effective. Despite the government policy of decentralization, most managerial, administrative and communication problems have not been addressed. The program approach will be instrumental infacilitating this process. Devolutionto districts will be a major change inthe way inwhich the program i s implemented and will be supported by the project. This will be a major focus of the annual review process. Beneficiary consultation and involvement will be strengthened and made more systematic. 16 53. The sector program o f which this project is a part provides an important vehicle for developing national implementation systems and capacity in a non-threatening manner. The establishment and expansion o f common implementation systems for all the operations supported in the sector i s an important feature o f the program, both to build capacity and to reduce waste on parallel systems and procedures. Joint government/partners annual reviews would provide a viable instrument for reviewing progress towards objectives, sustainability and quality o f services. Reduced compartmentalization o f MSASF units and projects would be achieved through program and unit reforms, which shift focus from single disease to a holistic program approach, integrating promotional, preventive and curative services, stronger publidprivate partnership and improved performance-based monitoring and evaluation o f the whole sector program. Sector-wide accountability would be improved and duplication will be greatly reduced as greater focus i s placed on results indicated by expanded access to quality o f care to the poor and vulnerable population groups. 54. The joint annual reviews involving all partners supporting the sector will also provide opportunities to assess progress towards good governance and enhanced technical performance duringthe preceding year and plan for the following year. The GOC and partners will agree on priority activities to be undertaken under each o f the operations they finance and allocations o f resources for the coming year. A smaller review will take place in the off six months, in February, which will focus more on technical and service related issues. In due course, annual reviews will be introduced at Regional and District levels, leading to an Annual National Health Assembly. 55. For strategic reasons, the project will be implemented with phased emphasis on: Initiation (2 years), scaling up (2 years) and consolidation (1 year). A mid-termreview i s envisaged at the endo fthe first phase and will inform the scaling up. C. Monitoringand evaluationof outcomedresults 56. An efficient and effective monitoring and evaluation system permits key data regarding activity planning and resource allocation (financial, human and material) to be available in a timely manner for making informed planning and implementation-related decisions based on evidence from all levels o f the health system. Currently, the few monitoring and evaluation activities implemented in the sector are highly centralized, are neither systematic nor comprehensive, nor do they adequately meet the information needs o f the sector. The project will support the development o f an appropriate monitoring and evaluation system strategy and national plan for the sector, including the identification o f appropriate indicators for tracking activity progress (monitoring) and assessing results (evaluation) o f implementation of the PNDS. The system to be developed will address informationneedsby subject (financial, programmatic, etc.) andby type (inputs, processes, outputs, outcomes, impact), specifying information periodicity and bi- directional flow, for key actors at central, intermediate and peripheral levels. In order to build capacity in this domain for the sector, the project will support two international monitoring and evaluation experts to steward the development and implementation o f the comprehensive health sector monitoringand evaluation system. 17 57. The conceptual framework o f the monitoring and evaluation system for the sector and the operational plan to be developed will specify at each level (i.e. community, health facility, health district, health department, etc.) needs in terms o f human resources (including responsibilities and required competencies), supplies, and equipment for the system to function in such a way that all parties, from central level steering/advisory committees to decentralized level actors, have timely informationthey needfor making informedplanning and implementation-related decisions. 58. The components o f the monitoring and evaluation system will include the following: (i) routinely reported health management information, including facility-based information on service activities, illnesses and deaths, logistics management information related to tracking equipment and consumables (e.g. pharmaceuticals and bed nets), among others; (ii)epidemiologic surveillance, particularly for epidemic-prone diseases and sentinel site activities (e.g. tracking illnesses, insecticide-resistance, treatment efficacy and pharmacovigilance); (iii)periodic survey assessments, at both household and facility levels; and (iv) health system operations research, for example, to identify "best practices." In addition, service delivery maps will be periodically updated. 59. Activities to support development and operationalization o f the M&E system for the sector have been proposed and included in the Program of Work. Indicators for tracking progress of both the implementation o f the PNDS more broadly, and IDA-supported activities more specifically, have been identified and are detailed inAnnex 3. D. Sustainability 60. Sustainability o f the proposed health program, including IDA funded project activities has both programmatic and financial perspectives. Programmatic Sustainability 61. Programmatic sustainability will be ensured through: a) Rational expenditure and budgetary reform: the Medium-Term Expenditure Framework (MTEF) process has been initiated and the project will support budgetary reform initiatives to enhance fiscal predictability, accountability and sustainability; b) Adopting a program approach: the program will introducejoint and transparent planning and eliminate the traditional project approach, which i s fragmented and has been shown to distort sector allocation priorities and difficult to sustain; c) Buildinglocal capacity: This will be a major focus o f the project. There will be no PIU, and government capacity will be built at all levels; d) Continued technical support by partners; and e) Public-private partnerships. 18 Financia1Sustainability 62. Financial sustainability will be assured through predictable and increased government allocation to the health sector and effective fiscal decentralization, including rational use o f available resources. Although donor support i s relatively small, it i s still critical to the overall integrity of the program and catalytic in many critical interventions such as fiduciary and institutional reforms, human resource development, infrastructure, quality o f services and M&E. Government expenditure 63. Financial sustainability of the program o f work (POW) depends to a large extent on improvement inthe government's budgetaryprocess and overall public financial management in Congo. As indicated in Annex 9, the current public expenditure management system i s weak and highly complicated. The multiplicity o f steps in executing public expenditures would adversely affect the execution o f POW and the Ministry o f Health's expenditures on health services provision. To ensure sustainability o f overall health expenditures, the budget execution process will be simplified. Donor support 64. Sustainability of the overall POW will also depend on the level o f donor support. As shown in table 1 o f Annex 9, currently there is little donor support to the health sector and government spending far outstrips donor contribution. The POW calls for appropriate levels o f predictable donor support to finance project activities. In addition, under the leadership of UNDP, all the UNtechnical agencies have committed to harmonizationo ftheir support. Fiscal decentralization 65. The sustainability o f the POW at the decentralized regional and district levels depends on the extent to which funds flow to primary health facilities. Although the operational budget execution has been decentralized, with centres de sousordornnancement directing budgetary processes at the lower levels, the regions and districts still have difficulty in accessing sufficient operational funds. Effective and efficient allocation mechanisms will be put in place to ensure that funds are directed to priority programs at the lower levels o f government. Innovative approaches such as conditional specific purpose and matching grants mechanism will be piloted to ensure that funds are equitably transferred to the regions. On the investment side, the centralization o f investment expenditures at the DEP has been inefficient, leading to deterioration o f most health infrastructure and equipment. DEP will be made more functional to ensure that investmentexpenditures are directed to improving health facilities at all levels. 19 E. Critical risks and possible controversial aspects 66. This project does not have controversial aspects. Table 3: Risk Ratings Risks Risk mitigation measure IRiskrating Country risks Political and security risk: These risks cannot be mitigated at the project level. At the H although the security situation is country level, the political agreement between the generally good throughout the Government andNtoumi reached inApril 2007 is a good country, the Pool region development, and its successful implementation, including a remained the most volatile area. demobilization and reintegration program, will critical to restore security and peace. A donors-supported demobilization and reintegration program is ongoing, and will cover former rebel ~ O U D S . Sector risks I Country Ownership o fProgram: Stewardship is an important part o f the project design. The M a comprehensive approach inthe approach has support o f all stake holders. Ownership built health sector is new to Congo into project preparation from the beginning and is led by the and presentsa significant Minister and a strong technical team, representing the departure from `business as government, academia, private sector and civil society. usual'. The challenges may tax Strong community component o fproject the patience o fmanagementand reduce commitment to reform. Financial sustainability o f the State commitment to the sector has been reconfirmed. M sector may bejeopardized by Government commitment to achieve the Abuja targets for lack o f adequate finds allocation to the sector. There is evidence o f increased allocation to the sector inthe last two years. Resistanceto decentralization o f Government has initiated administrative decentralization. M the sector Projectrisks I Technical design: Continued Allocation and `ring-fencing' allocation to be assuredin M focus on big infrastructure such design and annual work plans. as hospitals may limit effective focus on primary health care and essential healthpackage 20 Risks Riskmitigationmeasure Riskrating Fiduciary risks: lack o f A comprehensive risk mitigation approach for fiduciary H transparency inproject risks i s included in annex 7. processing and risk o f corruption Partially use o f IDA FMprocedures is requiredfor this and misuse o f funds project as well as the inclusiono f a PFM capacity building component inthe program. The ongoing PFM reform financed under the Governance and Capacity Building project will help strengthen the government fiduciary capacity (budgeting, reporting, procurement and auditing) Relyingon a dedicated FMteam within the ministry supported by an international FMExpert Ex-ante and ex-post control o f funds allocated to implementing entities and regional offices o f the MinistryofHealth Internal audit function contracted with the Inspection Generale des Finances, supported by two internal auditors within the Ministryo fHealth Annual external audit, the scope o f the audit will include review expenditures incurred at the decentralized level Social and environmental A comprehensive environmental and social assessment L safeguards: Some aspects o f undertaken and approved by IDA. Medical Waste rehabilitation and o f medical Management plan under HIV/AIDS project already supplies constitute updated. environmental risk to communities. Institutional arrangements risks Institutional reorganizationo f Strong focus on capacity building inPlanning, Financial M central and decentralized andHRmanagement and stewardship. Incentives and MSASF units may experience results-basedmonitoring and evaluationduring delays. New roles and implementation. responsibilities might be respectedonly over time. HRconstraints (shortages, HRanalysis undertaken and HRHdepartment established. M limited capacities and uneven Special focus on training o f managers and results- based deployment) could slow reforms, approach and incentives. HR recruitment, deployment and affect service delivery and innovative retention are a major part o f the program. outcomes. Special attention to be given to in-service training and quality o f care. OVERALLRATE M 21 F. Loadcredit conditions and covenants 67. Effectiveness Conditions 1. Establishment o f a Procurement Unit within the MSASF: recruitment o f international procurement expert and national procurement staff and provide initial training for national procurement. 2. Establishment in the MSASF o f the financial management system including (i)the employment of the InternationalFM expert and the Financial Director and the Treasurer, (ii)the adoption ofthe FMProcedures manual; (iii)the assignment oftwo internal auditors coming from the Inspection Generule des Finances to work in MSASF, and assumption o ftheir functions. 3. Adoption o f new organizational structures for the MSASF, establishing the new posts o f Secretary General o f MSASF, Director General positions, Head o f Finance, Head o f Planning and Research, Head o f Human Resources and Head o f Monitoring and Evaluation. 4. Completion and adoption o fthe Project Implementation Manual satisfactory to IDA. 68. DatedCovenants 1. International recruitment o f technical experts: Human resource expert (l), Monitoring andevaluation(2), andPublic health specialist (1) by October 30,2008. 2. Recruitment o f the local accountants and the management accountant (two months after project effectiveness). 3. Procurement and installation o f accounting software acceptable to IDA and training o f the users (three months after project effectiveness). 4. Training o fusers o f FMProcedures manual (three months after project effectiveness). 5. Selection o f the external auditing firm (three months after project effectiveness). 6. Submission to IDA (i) its approval, o f the Recipient's draft annual work plan of for activities proposedfor inclusion inthe Project duringthe following year, and (ii) the comprehensive annual budgetfor the PNDS incorporating GOC anddonor contributions for the following year by October 15 ineach year. IV. APPRAISAL SUMMARY A. Economic and financialanalyses 69. The IDA supported project which constitutes part o f the comprehensive PNDS is designed as a sector development project over the medium term (2008-2012). It derives from a comprehensive detailed activity-based Program of Work for the PNDS,which was prepared in close collaboration with key development partners in Congo including EU, AFD, WHO, UNFPA, UNDP, UNICEF and China. These other development partners are supporting other 22 parts of the PNDS in parallel with the IDA-financed project, with funds ranging from approximately US$1.O million to US$15 million. 70. The project analysis demonstrates it has a sound economic justification on the basis of improvingequity and reducingpoverty through investmentinhealth; harmonizing multiplicityof off-budget donor interventions inorder to significantly reduce management burdenand improve effective implementation o f health sector programs and; ensuring allocative efficiency by strengthening and improvingdelivery o f the Pucquet Essentiel des Services . Congo spends less o f its national budget on health compared to other SSA countries despite having high burden of disease with infectious diseases and maternal and child health problems accounting for between 60%-90%. The low level o f allocation to the sector vis-a-vis demand for health services justifies the need for investing in health in order to improve the health status of the population. To determine the economic viability o f implementingthe project, the project team conducted a Cost- Benefit Analysis (CBA), which compared monetized benefits with costs and resulted in a positive Net Present Value (NPV) o f $11,894,241,000. The results indicate that the project would generate the expected benefits. Further analysis conducted to address the uncertainties o f assumptions made under the CBA also resulted in positive benefits for all the three variables changed. 71. The financial analysis of the project examined overall resource allocation to various activities and found it to be sound. The analysis also examined the sustainability of the PDSS expenditures in terms o f government spending, donor contributions to the sector, and fiscal decentralization. Overall, the methods for costing, resource allocation and requirements employed by the project team provide a reasonable basis for developing the project. The analysis also shows that the project was prepared under a sound macroeconomic environment: low inflation rate, consistent GDP growth rate, significant reduction innondiscretionary expenditures (domestic debt); andpositive fiscal balance. Thus, the government will be able to meet its annual contribution to the project if the current macroeconomic environment i s sustained. The analysis also depicts strong donor commitment to sustaining the POW resources with a great number o f donors contributing substantially to overall resources. B. Technical 72. The design o f this project i s in response to the identified gaps and opportunities in the health sector, experience with IDA and other donor supported projects in Congo as well as lessons learned from other countries inthe region. It is also based on analytical studies supported by both the Bank and development partners. The DHS (2005) report supportedthrough the M A P project was the first in Congo and provides solid socioeconomic baseline indicators for the country. Most importantly, the design addresses the leading causes o f morbidity and mortality in Congo, andtherefore aims at accelerating the attainment o f the MDGs. 73. A key focus of the design is the delivery of the PSE whose elements reflect the stated focus on combating the major causes o f morbidity and mortality. The elements consist o f cost effective interventions o f proven value. The design, however, recognizes the futility o f trying to deliver the PSE through a dysfunctional health delivery system, a fact that underpinsthe choice o f the comprehensive reforms for the sector as a whole. The PNDS and PSE have received 23 intensive support from both local and international partners, as has the integrated approach. The consultative approach inthe preparation o f the POW, the M O U and planned annualjoint reviews have givenhope for a new beginningto health dialogue inthe country, setting a solid foundation for public private partnerships, community participation and result- based focus and accountability. 74. Multiple factors account for good health, and the adversity and multiplicity in these factors has contributed to the worsening health status o f Congolese. The civil war destroyed Congo's fragile health infrastructure and public health services. The sector must now make a critical self examination and address inherent problems, starting with its own stewardship, and examine addressing both demand and supply issues. Ongoing political commitment to good governance in Congo and support from the Bank and IMF provides a unique opportunity for sectoral reforms that would otherwise be unimaginable in Congo. The design takes into account all these factors, provides for requisite technical support from partners, and underlines the importance o f primary health care, community participation, equity and multi-sectoral inputs for achieving the MDGs. 75. The project supports selected activities from the 5-year comprehensive POW of the MSASF, which is based on the PNDS and provides a basis for harmonization of the activities andwork plans of partners, various departments within the MSASF and other sectors. The POW also defines more clearly the roles and responsibilities o f institutions and stakeholders at all levels o f the health care system in Congo in order to enhance accountability for results. Finally, the POW emphasizes ownership and capacity buildingfor leadership bythe Congolese. C. Fiduciary 76. Congo i s inthe process o f major fiduciary reforms, with support from IDA'SGovernance Project (Projet du Renforcement des Capacites de Transparence et de Gouvernance -PRCTG). A Public ExpenditureReview (PER) is also underway. The HIPC initiative andthe I-PRSP are also being finalized with support from both the Bank and IMF. In this context, the Plan d'Action Gouvernemental sur la Riforme de la gestion des Finances Publiques (PAGGEFP) awaits final approval while Le Comiti Interministiriel de Pilotage de l'itude sur la riforme de la gestion des investissements publics i s ready. L'Observatoire concernant la Lutte contre la Corruption has beenestablished and Commission sur les Riformes de la Gestion des Marchis Publiques is being instituted. 77. A procurement capacity assessment that was carried out for MSASF by the Bank indicated a high risk rating for the program and specific actions have been recommended to mitigate the identified risks (see Annex 7). The main risks identified were unfamiliarity with procurement procedures o f multilateral financial institutions, weak procurement systems and unreliable quantification of requirementsfor health sector goods. The actions planned to address the deficiencies in the project are: (i) delineation o f fiduciary responsibilities between Finance and Planning Ministries and the sector, (ii)establishing a strong procurement unit and clear policies for the sector, (iii)intensive training o f procurement focal persons - Accounting, InternalAudit and COMEG staff, inthe principlesandpractice o fpublicprocurement, (iv) hiring o f a procurement specialist to mentor key MSAFS staff and to assist in procurement for the initial period o f the project, (v) setting o f standards and establishment o f regular reporting 24 requirements, (vi) institutionalization o f annual independent procurement audits, (vii) annual review o fprior thresholds based on findings from the procurement audits, and (viii) use o f Bank SBD's untila nationalprocurement system acceptable to the Bank has beendeveloped. 78. The financial management arrangements for the project are designed inthe context o f the country's post-conflict situation and with the objective o f building sustainable management. The arrangements aim to facilitate disbursements and to ensure effective implementation and use o f project resources and funds. 79. The findings o f CIFA and PEFA exercises, as well as the FM capacity assessment conducted during the project preparation, revealed several capacity shortages in financial management and procurement inthe MSASF. These weaknesses are: (i) insufficiently qualified staff in financial management at all levels of the health system, (ii) staffs weak familiarity with IDA financed-project procedures for reporting, disbursementarrangements, and auditing, (iii) no accounting system acceptable to IDA and lack of computerized and modern accounting tools at the Direction of Administration and Finance (DAF) and at regional levels, (iv) weak internal control and records keeping at DAF and other finance units, and (v) lack o f linkages between finance units o f the center, regions and health facilities. Furthermore, the assessment carried out duringfiscal year 2007 confirmed the lack o fboth an adequate tracking and reportingsystem and a formal accounting systemwithin line ministries, including the MSAFS. 80. Under the Transparency and Government Capacity Building Project, IDA provides support to strengthen the country P F M system. However, while remedial measures are being designed and put in place, such as the installation o f the Office o f Auditor General, the implementation o f the reform i s very slow, and it may take months before tangible results are achieved. 81. As a general rule, the Bank encourages the use o f country PFM system while implementingsector reform programs. However, the Government and its partners, including the Bank, however, recognized on the basis o f the findings o f the Bank and other donors' relevant analytical work (such as the CIFA, the PEFA and PER, as well as the assessment of the FM capacity o f the M o H carried out during the pre-appraisal mission) that the current country PFM system cannot be fully used for the purpose of implementing the Congo Health Project. Therefore, it was agreed to rely only on some o f the country PFM systems, mainly staffing, budgeting, internal auditing arrangements, to manage the FM aspects of the project. IDA FM procedures will be applied for accounting, recording, financial reporting, disbursement and external auditing arrangements. 82. The revamped financial management Unit o f the MSASF will be responsible for the project and will be headed by a qualified, experienced financial manager supported by an international FM expert selected on a competitive basis. The International FM Expert will provide technical assistant to the team as well as training to the overall FMteam o f the MSASF. The FMteam o fthe project will be composed o f civil servants recruitedby the MSASF. The FM team will be responsible for approving payments to contracted service providers, suppliers o f equipment and goods, and implementingagents and submittingquarterly consolidated unaudited InterimFinancial Reports (IFR) and semi- annual audited financial statements to the Bank. The internal audit function o f the project will be under the responsibility o f the "Inspection General 25 des Finances" (IGF). The IGF will assign two experts to carry out the work. The team o f internal auditors will review the financial reports submittedby the implementing agents and will carry out regular internal audit controls, includingverification o f eligibility o f expenditures ex post and physical inspection o f works and goods acquired by the project at the central and departmental levels. 83. One designated bank account maintained by the FMteam working in the project and will be opened in CFA in a commercial bank acceptable to IDA. Disbursement from the IDA grant will be Transaction-Based Disbursement Method (replenishment, reimbursement). The Transaction-Based Disbursement Method will be used during at least the first eighteen months o f project implementation. Thereafter, the option o f using the Report-Based Disbursement method could be considered subject to the quality and timeliness o f the consolidated IFR submitted to IDA by the MSASF. In this case, cash forecast for the next six months will be included inthe quarterly IFRs submittedto IDA. Eligible expenditures(maximum US$3 million) beginning from July 1, 2008 will be reimbursed retroactively by IDA as soon as the project is effective. 84. The "Cour des Comptes" the SupremeAudit Institutionwas established in2005 but is not fully operational and its current staffing arrangements do not allow relying on this institution for external audit purposes. Therefore, a qualified, experienced, and independent auditor (external auditor) will be appointed on approved terms o f reference. The external financial audit, including eligibility of expenditures and physical inspections, will cover all aspects of project activities implementedat central and decentralized levels and will be carried out on a semester basis at least for the first two years o f the project implementation. 85. Appropriate actions will be taken and diligently followed to address the critical challenges observed during the assessment. Detailed financial management arrangements including the status o f conditions of effectiveness and dated covenants are presented inAnnex 7. D. Social 86. A social assessment was carried out as part o f project preparation and was shared with major partners and disseminated in line with Bank requirements. The assessment defined objectives, principles and procedures that would guide any land acquisitions as well as compensation to enable MSASF to carry out additional construction. The agreed framework for the potential resettlement is inaccordance with the WB's OP 4.12. Potential resettlement would be in compliance with the land tenure system in Congo (Laws no9-2004 of March 26, 2004, no 10-7004, o f 26 the March 2004 and no 11-2004 o f 26 March 2004) that define the general principles applicable to land ownership in Congo and the procedures for the appropriation o f privately owned land for public use. Within the context o f the project, any differences between national land tenure laws or compensation provisions and the provisions o f the Bank's OP 4.12 would require that the latter be applied. Persons who legally own rights and own title deeds would have formal rights to land and other compensation. Persons who do not have formal rights or title deeds would only receive aid for resettlement. An Appropriations Commission will be coordinated by the Ministry of Land Reforms and Preservation o f Public Properties with membersfrom a number o f organizations, including the Pygmies.Reconciliation andMonitoring 26 Commissions have been set up in affected communes to register complaints, oversee resolution o f conflicts and follow up on resettlement compensation (see Annex 10). 87. Inaddition, the Pygmies are identifiedinthis project as one of the vulnerable groups that would be targeted through specific interventions in line with the Government o f Congo's policy to integrate the Pygmies into the Congolese society. A draft law for Pygmy protection and integration is under discussion in Parliament. The PDO specifically targets vulnerable groups and outlines interventions in Sub-Component 4.4, whose objective i s to ensure equitable access to services for vulnerable and underserved groups, such as the Pygmies, women and children.As part of the project, a study i s planned to identify barriers to service delivery, participation and equityfor these groups. The findings o fthis study will beusedto strengthen delivery o feffective interventions for the Pygmies. Sub-Component 4.3 aims to build local ownership and community participation in delivery o f services. Under this component, local NGOs working with the Pygmies will be contracted to buildthe capacity o f the Pygmiesto participate inarticulating their special needs. This will include rehabilitation o f health facilities, establishment o f outreach services and strengthening o f prevention programs, health education and behavior change communication. Finally, the project has identifiedspecific indicators that will be monitored on a continuous basis to inform on progress among the Pygmies and other vulnerable groups. An Indigenous Peoples' Planning Framework (IPPF) has been prepared under OP 4.10 for the Project E. Environment 88. Project implementation could have negative environmental impacts mostly resulting from: i)the buildingand renovation o f health facilities (disruption o f the environment, solid and liquidwastes generation, private landoccupation, etc) and, ii)mismanagement ofmedicalwastes at the level o f health care infrastructures. Inaddition, there i s the potential quarry exploitation for buildingmaterials that could cause negative impacts to the environment and requirerestoration actions after use. 89. To address potential future impacts, an Environmental and Social Management Framework (ESMF) and Resettlement Policy Framework have been prepared. The ESMF includes an analysis o f national institutional and legal framework within which the project will be implemented. An essential component for the ESMF of the Project is its Screening Process o f relevant undertakings. This process underlines the environmental norms and standards that will be applied in the project activities and the environmental evaluation procedures that may be needed, with special emphasis given to measures addressing the requirements of the Safeguard Policies. The ESMF will allow project implementers and local communities to progressively monitor any environmental and social impacts, based on a monitoring check-list, and to develop mitigation or compensation measures, on the basis o f clear, precise and operational indicators. F. Safeguardpolicies 90. The project will build and rehabilitate health facilities and support delivery o f heath services that will produce biomedical waste. The project has therefore triggered safeguard policies OP/BP4.0 1 (Environmental Assessment), OP/BP4.12 (Involuntary Resettlement). As it 27 involves indigenous peoples, OP/PB 4.10 (Indigenous Peoples) is also triggered. Inaddition, the project has complied with the ten (10) Bank Safeguard Policies requirements as well as OP/BP 17.50 on Public Disclosure, which requires that all environmental safeguarddocuments be made available in-countryand at the Info shop before disclosure and appraisal. Safeguard Policies Triggered by the Project Yes No Environmental Assessment (OP/BP 4.0 1) [XI [I Natural Habitats (OP/BP 4.04) [I [XI Pest ManagementCOP 4.09) [I [XI Physical Cultural Resources(OP/BP 4.11) [I [XI Involuntary Resettlement(OP/BP 4.12) [XI [.I Indigenous Peoples (OP/BP 4.10) [XI [.I Forests (OP/BP 4.36) [I X I Safety o f Dams (OP/BP 4.37) [I [XI Projects inDisputedAreas (OP/BP 7.60)* 11 [XI Projects on InternationalWaterways (OP/BP 7.50) [I [XI G. Policy Exceptions and Readiness 91. The project does not seek any policy exceptions. 'Bysupportingtheproposedproject, theBankdoesnotintendtoprejudicetheJinaldeterminationof theparties'claimsonthe disputed areas 28 Annex 1:Countryand Sector or ProgramBackground REPUBLICOF CONGO HEALTHSECTOR SERVICESDEVELOPMENT PROJECT A Background - 1. In 1999, Congo began a phase of rebuilding the country after the cessation of armed conflict. The reconstruction has led to a gradual restoration of the authority of the state, and the implementation o f institutional and economic reforms. Congo's economic prospects are promising but its output i s heavily reliant on oil, lacking in diversification and burdened by an unsustainable external debt. Basic infrastructure became obsolete or was destroyed during repeated armed conflicts. Thus, the government has embarked on the I-PRSP process as an expression o f its commitment to rebuilding the country and improving the living conditions o f people. B- Macroeconomics 2. At the macroeconomic level, studies have shown that the period 2000-2004 was marked by the end o f armed conflict and a gradual revival of the real GDP growth, with a rate o f 4% mainly due to the favorable international situation. From 2005, the favorable economic environment in terms o f trade, particularly the increase in oil production and prices, as well as the dynamism of the non-oil sector (transport, telecommunications and other services), helped consolidate and sustain economic growth, which reached 7.9% in 2005, and has stayed around 7% since 2006 as peace reigned in the country. Similarly, there were encouraging economic results with the consolidation o f the monetary situation, improved balance o f payments, and a debt burden which has somewhat declined. The current account balance grew considerably in 2005 to approximately14% o f GDP. C- Poverty 3. Various studies show that the stronger growth of recent years has neither helped employment nor improved the quality o f the workforce whose productivity remains low. The effects o f growth continue to be unevenly distributedwhile the social indicators suggest a sharp deterioration. The proportion o f the population living below the poverty line (CFA 544.40 per adult per day) (ECOM 2005) i s estimated at 50.7%. This average figure masks important inequalities. As shown in Table 1, the magnitude o f poverty is more pronounced in semi rural areas (67.4%), followed by rural areas (64.8%) and in other towns (58.4%), whereas it i s lower in urban areas, mainly in Brazzaville and Pointe-Noire where it reached 42.3% and 33.5%, respectively. Further evaluation o f poverty shows that women-headed households are more vulnerable to poverty (58.2%) than male-headed ones (48.8%). Similarly, households are poorer where the head o f the householdhas no education (69%) compared to households where the head of household has a primary education (61%), secondary education (50%) and higher levels (30%). In addition, the household size impacts the incidence o f poverty with the level being 52.6% in single-parent households and 47.3% in extended family households. 29 Table 1: Poverty indices by geographic region, Congo 2005 Poverty Rate Population (%.) (%I Brazzaville I 42.3 I 24.2 I Pointe Noire 33.5 15.5 Other Towns 58.4 6.8 Semi Urban 67.4 9.4 Rural Areas 64.8 44.2 Total 50.7 100.0 4. Mindful o f past failed strategies, the Government has developed a strategic vision (Nouvelle Esperance) aimed at achieving the Millennium Development Goals (MDGs) and easing of the debt burdenthrough the HIPC Initiative, growth, and poverty reduction. Achieving the MDGs requires successfully dealingwith the following challenges: the promotion o f governance through sound macroeconomic policies and institutionalizing a framework conducive to private sector development; investment in the rebuilding o f infrastructure and human capital to improve the competitiveness o f the economy, social security coverage for the poor, the quality o f the education system andhealth system; diversifyingthe productive base inorder to reduce dependence on oil (and hence the external shocks) and expand domestic employment opportunities; and Promotion o f strong equitable and sustained economic growth. As showninTable 2 shows Congo is unlikelyto meet the MDGs 30 Table 2: Progresstowards the MillenniumDevelopmentGoalsin Congo MillenniumDevelopment 1990 MDG Currentstatus Likelihoodof achieving Goals Benchmark (year) target by 2015 -1.Eliminate extremepoverty. Poverty and Hunger 35% (estimated) I 50.7% (2005) I Low 2. Achieve universalprimary education - Increasecompletion rateto 100%. 100%(estimated) 72% (2006) Medium 3. Promotegender equality - Raiseratio of girlsiboys in primary schoolto 100%. 1Yo (2005) 0.93% (2005) - Raiseratio ofgirlsiboys in High secondary school to 100%. 1% (estimated) 0.75 (2005) 4. Reducechild mortality - Reducechild mortality inchildren under 5 by two-thirds. births births(2005) -5.Reduce the rate ofmaternal Improvematernal health mortalityby three-fourths. births (estimated) births (2002) 6. CombatHIV/AIDS, malaria & -other diseases Fight against HIViAIDS 3.8% 4.2% (2005) High 7. Ensureenvironmental -sustainability Halve the proportion o f individuals without access to safe 75% (estimated) 26.5% (2005) Low water. urces: ECOM, EDS, 2005, RESEN 5. Poverty reduction requires high growth rates and effective targeted budget resources to pro-poor policies (Table 3). Thus the I-PRSP i s based on these pillars: 0 consolidation o f peace, security and improvement o f good governance; 0 promoting economic growth and stable macroeconomic framework; 0 improving people's access to basic social services; 0 improving the social environment; and 0 Strengthening the fight against HIV / AIDS. 6. Successful national poverty reduction strategies backed by efficient measures, to monitor the system through rigorous assessmentto beputinplace, includingthe targets andtimetable for achieving them. 31 Table3: Allocation of publicoperatingexpenditures(in billionsof CFA) Source: DGPD/DPI (2007) D-HealthSector Organization 7. The health system i s organized inthree levels: central, regional and primary.' The central level plays a strategic and normative role for planning, monitoring, evaluation, coordination mobilization and allocation o f resources. The regional level (12 Departments) plays a technical support role for the health districts (Circonscriptions Socio Sanitaires (CSS) for information exchange, implementing national norms and supervision o f the Districts. In addition, the Department provides oversight for implementation of health activities, studies, planning and training and resource management (financial, human and material). The primary level is the operational unit o f planning and implementation o f the PNDS. It i s represented by the CSS which are subdividedin "health areas" (aires de sante). Each CSS i s comprised o f a network o f health facilities, both public and private (health centers, integrated health centers (CSI), and referral hospitals). 8. Congo's population o f 3.9 million i s growing at a rate o f 2.8% per year. The Total Fertility Rate (TFR) i s 6.3, one o f the highest in Sub-Saharan Africa. Other health indicators such as the neonatal mortality rate, child mortality rate and maternal mortality ratio as well as the highincidence ofinfectious diseases indicatethe poorhealth status ofthe people. Dtcret no98-256 du 16juillet 1998 portant organisation de la direction generale de la santC Decret no2003 - 167 du 8 aoiit 2003 portant organisation du ministere de la sante et de la population 32 Table 4: Major Health Indicators Indicators 7 Target Life Expectancy at Birth 52yrs I 51.3 yrs 48 yrs 55 yrs Neonatal Mortality Rate 33 per 16.5 per 1,000 lb 1,000 lb Child Mortality Rate 75 per 37.5 per 1.OOO lb 1.000 lb 1,000 lb 1,000 lb Child and Youth Mortality Rate 117 58.5 Proportion of one (1) year olds vaccinated against measles (VAR) 75% 36% 66% 100% Proportion o f one (1) year olds vaccinated +-- against yellow fever (VAA) 31% 100% BCGCoverage Rate 89.6% 100% DTC3 Coverage Rate 65.8% 90% Health Care Access Rate 49.0% 75% Polio 3 Coverage Rate 66.4% 90% I MaternalMortality Ratio 890 781 IIII 390 Proportion o f Deliveries assisted by Qualified Personnel 86.0% 100% VAT 2 Coverage Rate 64.5% 100% Utilization Rate o f one Contraceptive Method 12.7% I 80% Proportion o f Women who Aborted after five (5) months o fpregnancy 2.8% 0.5% Malaria Incidence Rate Tuberculosis Incidence Rate Proportion o f Tuberculosis cases detected and I healed according to the DOTS strategy 69% 71% 100% Plan OMD and OMD2004 Report, PNDS 006 lb = live births * 33 Table 5: Number o f Health facilities in Congo ZU15 Health Facilities 2005 Target CSI 153 217 CSI-PMAE 74 121 District Hospital 27 41 General Hostital 5 7 C H U 1 1 Other Health Centers 50 Total 2015 Health Personnel * 2005 Target Number of inhabitants per doctor 4,680 10,000 Number of inhabitants Der Dharmacist 32,970 10,000 Number of inhabitants per birth attendant 5,9 18 5,000 Number of inhabitants per nurse 1,920 5,000 Number of inhabitants per lab technician 7,092 5,000 9. Health care services are provided in 1,712 both public and private facilities (See Table 5 data for 2005) out o f which 49.1 % are located inurban areas, 34.8% inrural areas and 16.1% in semi-urban areas. In general, health centers and public hospitals lack materials, technical equipment and essential supplies. Thus, 17.6% o f public health facilities were closed due to dilapidated infrastructure, lack o f equipment and personnel. Private facilities which represent 50.2% o f health frontline facilities are located primarily inBrazzaville and Pointe Noire; but are unorganized and poorly regulated. 10. From 2002 to 2006, the number o f health personnel in all categories, increased from 5,130 to 9,491, an increase o f 46% reflecting a recent recruitment drive by the public service which did not address major urban-rural disparities. The supply o f essential medicines and supplies depends mainly on imports. The public non-profit supply system, the newly formed Congolese Essential Generic Medicines Agency (COMEG), i s mandated by the State to procure and distribute essential medicines and supplies to public and non-profit health facilities. Its development has been supported by the European Union, within its health systems support project inCongo (PASCOB). CommunicableDiseases 11. Malaria i s a major public health problem in Congo, affecting the entire territory, with transmission occurring nearly year-round in most areas. Suspected malaria contributed to 54% o f facility-based reported deaths among children under five (DLM 2007). Tuberculosis is an 34 important cause of morbidity and mortality in Congo, with nearly 10,000 new cases recorded each year (approximately 36% are associated with HIV). Several Nedected Tropical Diseases (trypanosomiasis, schistosomiasis, Buruli ulcer and onchocerciasis) are now resurgent in Congo despitepast and ongoing preventioncampaigns and the provision o f treatment inaffected areas. 12. Maternal Health: Poor reproductive health status in the Congo i s reflected in the high maternal mortality ratio, (estimated at 781 maternal deaths per 100,000 live births, DHS, 2005). The main causes of maternal deaths are: induced abortions (41%), bleeding during delivery (40%), post-abortion infection (18.8%), post-partum hemorrhage (12.7%), hypertension- eclampsia (1l%),dystocia with their untoward consequences (including uterine rupture, and vesico-vaginal fistulas, ascending infections), HIV / AIDS (6%), malaria and other (20%). 13. Child Health: . Infant mortality increased from 65 to 87 to 75 deaths per 1,000 live births, in 1995, 2000 and 2005 respectively. Similarly under-five mortality increased from 101 to 131 and 117 per 1,000 live births in the same period.. The leading causes o f child mortality have remained unchanged for years; these include malaria (3 l%), diarrhea (26%) acute respiratory infections (14%), non-malarial anemia (6%) and AIDS (7%). E The NationalHealthDevelopmentPlan(PNDS) - 14. Serious efforts to improve access to quality health services began inthe early 1990s. The National Health Development Plan (PNDS 1992-96) was interruptedby civil unrest. The latest PNDS for 2007-2011 focuses on the MDGs within the context o f the Nouvelle Esperance and aims to improve the performance o f the health system inorder to reduce the burdeno f morbidity and mortality, and promote health by strengtheningthe care and services at the district-level, general hospitals, specialized support services as well as strengthen institutional capacity and partnership coordination. Expected results include: development and improved management of human resources inthe health sector; development o f strategic plans for managing disasters and emergencies; development o f a health research agenda including basic research oriented towards priority programs (HIV/AIDS, Malaria, Tuberculosis etc) and operational research on the health care system; improving integrated health center coverage streamlined from 21% to 80% for all Circonscriptions SocioSanitaire (CSI), inaccordance with the national health coverage plan; the establishment, equipping and staffing of at least one referral hospital in each administrative region (department) ; reinforcing the operational capability o f COMEG to improve the supply chain, quality, availability and accessibility o f essential generic medicines and supplies for use at all levels o fthe healthcare system; strengthen and streamline active community participation in the management o f their own health and in the co-management o f the health system as a whole through institution o f viable health committees (COSA), hospital committees (COGES and CODIR) and the training and effective use o f community health workers incommunity-based distribution and treatment activities. 35 15. Implementing the PNDS requires substantial mobilization o f funds and provision of technical support to supplement sharply increased GOC budget allocations and commitments to long-term financing inthe sector. F HealthExpenditures - 16. Public expenditure on health (31.4 billion CFA in2005) has been relatively low. In2005, the Congo only 4% of public expenditurewent to health, (one o f the lowest in SSA) which still falls significantly below the Abuja target of 15%. In terms of household expenditures, the richest quintile spends on average four times more than the poorest quintile on health. However, the poorest spend a larger percentage oftheir total expenditure on health (7.1%) compared to the wealthiest quintile (4%). It i s estimated that households that are obliged to spend more than 5% on health-related expenses experience are often unable to cope with the negative effects of ill health. Table 6: HealthExpendituresandPercentof TotalExpenditures,Congo 2005 PercentofTotal ByHousehold Per Person By IllnessEpisode Expenditure Poorer 20,993 3,209 881 7.1 Quintile2 29,85 1 5,250 1,404 6.1 Quintile3 52,426 9,506 2,6 10 7.3 Quintile4 61,038 12,924 4,009 6.0 Richer 88,777 22,434 6,267 4.0 I Total 54.768 10.679 2.927 5.1 Source: WorldBank calculationfrom ECOM 36 G Nutritionand Food Security - 17. Food insecurity and poor nutrition affect one third o f the Congolese population and these are reflected in signs o f chronic malnutrition diagnosed in health facilities. Food deficiencies disproportionately affect low-income households, children, pregnant and lactating women, the victims of conflicts, the unemployed and those infected and affected by HIV / AIDS. Fifty percent o f the population lives below the poverty line and their consumption does not meet minimumcaloric intake o f2400 kcal per day. Data from the 2005 DHS suggest that over 25% of children less than 5 years old suffered from chronic malnutrition half o f whom were a severe form. Vitamins and mineral deficiencies undermine psychomotor development of children and diminishhumancapital andeconomic growth potential. Factors contributing to food deficiencies andpoor nutritioninCongo include: Poor knowledge o f the right foods combinations, Absence of a coherent and effective national policy on agriculture and nutrition, Absence o f a tradition o f food production and weak state support to boost food production. Low capacity o fprocessing and conservation o f local food products Poor knowledge andpractices by parents inpreparation and balancing diets. H Water andSanitation - Water 18. Although Congo's water resources are abundant, safe drinking water i s very scarce for both urban and rural populations. The National Water Distribution Service (SNDE), supplies potable water in 21 localities but coverage rate scarcely exceeds 40%. Developing water distribution has not kept pace with the spread o f uncontrolled urbanization. Consequently drinkingwater is primarilyprovidedby the informal sector (private wells, dealer cans, or water tank trucks). 19. In some rural areas, potable water is provided by the State, NGOs or development partners with strong beneficiary communityinvolvement through water management committees butthe coverage rate is barely 11%. The rest o fthe populationdepends on unsafe sources such as shallow wells, rainwater, rivers, springs etc. According to the ECOM 2005, 10% o f households take at least one hour to reach a source o f drinking water; with distances between places of residence and the water points ranging from 0.5 and 1.5 kilometers. Sunitation 20. Sanitation conditions inthe Congo remainvery poor andhousehold and environmental sanitation conditions facilitate the spread o f disease. 37 I-Multi-sectoralActionsforHealth,Nutrition,WaterandSanitationinCongo 21. To achieve specified health sector objectives, the following strategies would be adopted: 0 Strengtheningand integrating nutrition potable water and sanitation activities in the health system at all levels. 0 Improving integrated management o f priority programs at all levels o f the health sector. Reorganization o f community local health insurance schemes for services not funded by the state budget.. 0 Improving the supply and distribution of essential and generic medicines in health centers including malaria treatment kits, PF supplies and Ivermectin. 0 Strengthening the IEC/BCC and community participationindisease control programs. 0 Intensificationo f the level treatment and prevention o f communicable diseases. 0 Developing and integrating maternal and child health services within the PSE Nutrition and Food Security 22. The overall objective for nutrition and food security is to improve the food and nutrition situation o f the population. Within the health sector, Congo intends to achieve this through: 0 Developmentof a consistent and effective national nutritionpolicy 0 Improved knowledge and access to good quality food. 0 Improved knowledge and practices for preparation and preservationo f foods. 0 Researchinto quality and promote local nutritious foods. Water and Sanitation 23. The overall objective i s to improve access to drinking water and develop sanitation facilities. Within the health sector, Congo will: 0 Improve water supply sources in all health facilities and collaborate with authorities to promote good governance inwater supply and accessibility. 0 Capacity building for monitoring water quality in collaboration with competent authorities 0 Promote through IEC/BCC access to drinkingwater inrural and urban areas 0 Develop systems o f individual and collective urban and rural sewage and storm water disposals incollaboration with communities and local authorities. 0 Strengthen operational capacities o f public health services and local authorities in managingexcreta, sewage and storm water and adopting o f appropriate technologies for low-cost management o f excreta. 38 Annex 2: Major RelatedProjectsFinancedby the Bank and/or otherAgencies REPUBLICOF CONGO HEALTHSECTOR SERVICESDEVELOPMENT PROJECT 1Donors I The IProject IAmount IPeriod IMainactivities IRemarks WorldB ik Transparency 22,000,000 2002- Support implementation o f HPIC Moderately and Governance USD 2012 triggers satisfactory Capacity Building Project (PRCTG) (IDA 3600) Emergency 41,000,000 2003- 1. Financing o f priority local Satisfactory Recovery and USD 2008 investments ($8 million) inall Community regions expect Brazzaville and Support Project Pointe-Noire (PURAC) 2. Support to the Decentralization (IDA 3798 and program H0530) 3. Support of economic reforms (telecom, forestry, postal service, HIV/AIDS and 19,000,000 2004- Multi-sector support to national Satisfactory Health Project USD 2009 HIV/AIDS program and financing (MAP program) of a DHS survey (IDA H0820) Support to Basic 20,000,000 2004- Capacity building and Satisfactory Education USD 2008 infrastructure Project (PRAEBASE) (IDAH1270) Emergency 19,000,000 2005- 1. Demobilization and Multidonor Reintegration USD 2008 reintegration o f ex combatants funded ProgramProject program. (MDW IModerately satisfactory Agriculture and 20,000,000 2008- 1. Rehabilitation and I Recentlv Rural Roads USD 2012 reconstruction o f rural roads) effective Rehabilitation 2. Financing o f micro-projects and Project (PRSA) :apacity building. (IDA Q5030) 39 Donors IProject IAmount IPeriod IMainactivities IRemarks EuropeanCc imission support to 49,700,000 2006- 1. Reconstructionand Supplemental Transport Euro 2009 maintenanceofroads finance sector's policy expected Protocol 1,985,840 2006- Ineligible expensesrelatedto Budget Agreement Euro 2008 previous Structural Adjustment support Program: 1.Rehabilitation o fruralroads (Project7 ACP COB56) 2. Rehabilitation of infrastructures to access to Odzalapark 3. Support to the fhctioning of Medicine's purchasing Centre (PASCOB Project) 4. Supportto Public finance reforms based on the Country IntegratedFiduciaryAssessment (CIFA) exercise. National 8,800,000 2005- 1. Supportto the supply of Program for Euro 2008 essentialmedicine products Medical 2. Support to local and smaller Development medical administrations. (PASCOB) Socio-economic 2,100,000 2006- 1. Rehabilitation of two bridges Rehabilitation Euro 2008 along the NationalRoadnumber 1 andRecoveryof (RN1) betweenMindouli and the Poolregion LoutCtC 2. Rehabilitation of rural roads through High Intensive Labor Works. Settingup of maintenance management systemat village level (800,000 Euro) 3. Reconstructionof 13 Integrated Health Center (CSI) and rehabilitation o fMindouli Hospital (1,300,000Euro). Program for 5,500,000 2003- Construction of community and rural micro- Euro 2009 social infrastructures inthe projects regions ofNiari,Kouilou, Cuvette and Sangha. Protectionof 6,688,000 2006- 1. Protection ofthe ecosystem: Environment Euro 2008 ECOFAC IV (3,738,000 Euro) 2. Institutional support for the development o fprotectedzones (2,950,000 Euro). 40 Donors 1Project 1Amount IPeriod IMainactivities IRemarks African DevelonmentBank I Economics' 1500,000SDR 2003- Management 2008 Support Project (PAGE) 2006- 2009 Administrations involved inthe execution, control, and the monitoring o f the public expenditures Multi-sector 14,800,000 2008- 1. Cleaning up o f some suburbs o f Joint with the Project for SDR 2011 Brazzaville IDA and socioeconomic 2. Reconstruction of health and AFD reinsertion education infrastructures, (including professional trainings) 3. Financing o f economic recovery activities France Fre - Financing o f around twenty 373,000 Euro Development projects inpartnership with local not disbursed (Micro-projects) NGOs in the sector o f education, health, and economic recovery activities. FSP Project - Rehabilitation and equipment o f support to training centers, Assistance to the Judiciary Police creation and equipment o f a technical and scientific Police Education 1. Support to educational reforms 1 technical Project AREPA 2008 at the primary level, training advisor 2. Statistical databaseon primary affected to education. the Government. 94,520 Euros not I disbursed. FSP Project - 500,000Euro I2005- Support to sustainable 1technical Forestry and 2008 management o f ecosystem and advisor sustainable environment (training and advice). affected to development the Government, FSP Project - Computerization o fDirectorate 1technical support to General o fPlanning and CNSEE, advisor planning and Establishment o f a planning and affected to monitoring o f monitoring systeminline with I- the public PRSP. Government. investments 41 Donors Amount Period Mainactivities Remarks 2006- Financing o f economic recovery 2008 micro-projects inpartnership with localNGOs. 2006- Support to higher education 1 technical Francophone Euro 2008 reforms, promotion o f French advisor and dynamics and language, support to national tW0 cultural initiatives in connection with international diversification UNESCO convention. experts will be affectedto the Government. UnitedState; Through Food for US$8,194,300 united Conflict Nations Affected areas World Food Program Through Various US$2,153,334 CurrentlyI I Wildlife environmental underway Conservation conservation Society projects World Conservation Union (ICUN) and World Resources Institute UnitedNatioi DevelopmentPi gram(UNDP) Governance 3,899,641 2004- 1. Support to the establishment support USD 2009 and operationalizationo fNational Program Commission to fight against Fraud and Corruption 2. Regular plenary sessions to Parliamentarians and other democratic institutions 3. Strengthening capacity o f political parties. Program to fight 3,257,225 2005- 1. Assistance inthe preparation o f against Poverty USD 2007 the I-PRSP, MDGs Annual Report, andNational Human Development Report 2. Promotion o fmicro-finance. Program for 1,500,000 2004- 1. Support to the preparation of a Part o f the Promotion o f USD 2008 strategy for environment's budget still renewable sustainable management needs to be energy and 2. Support to the preparation of a mobilized environment's wastes management plan for the sustainable city o fBrazzaville management 3. Dialogue on climate changing and bio-diversity. 42 Donors Project Amount Period M a i n activities Remarks HIV-AIDS 1,154,627 2005- 1. Support to the preparationand Part ofthe Program USD 2008 implementationo f a private sector budgetstill strategy to fight against HIV- needs to be AIDS mobilized 2. Strengthening capacity ofthe execution and coordination agencies (training and equipment) Community 1,594,597 2002- 1. Rehabilitation o fbasic Actions for the USD 2008 infrastructures reintegration of 2. Financing of income generated Youth and activities. Women IMF Poverty 54,990,000 2004- 1. Strengthening of Stopped in Reduction SDR 2009 macroeconomic conditions 2006. Staff Growth Facility 2. Improvements inoil sector monitoring transparency and budget program on management the way 5. Fiscal discipline. 43 Annex 3: ResultsFrameworkandMonitoring REPUBLICOF CONGO HEALTHSECTOR SERVICESDEVELOPMENT PROJECT ResultsFramework 1. An efficient and effective monitoring and evaluation systempermits key data regarding activity planning and resource allocation (financial, human and material) to be available in a timely manner for making informed planning and implementation-related decisions based on evidence from all levels o f the health system. Currently, the few monitoring and evaluation activities implemented in the sector are highly centralized, are neither systematic nor comprehensive, nor do they adequately meet the information needs o f the sector. The project will support the development o f an appropriate monitoring and evaluation system strategy and national plan for the sector, including the identification o f appropriate indicators for tracking activity progress (monitoring) and assessingresults (evaluation) o f implementationof the PNDS. Inorderto build capacity inthis domainfor the sector, the project will support two international monitoring and evaluation experts to steward the development and implementation o f the comprehensive health sector monitoring and evaluation system. Work has begunduring project preparation, and selected indicators to track progress of IDA-supported activities contributing to operationalization o f the PNDS are identified below. In addition, a more extensive list o f indicators for tracking implementation progress o f the entire Program o f Work has been initiated and will be further refined. 2. It is expected that improvement on the Project Outcome Indicators will contribute to reduced child mortality (MDG4), reduced maternal mortality (MDG5) and expanded control of major communicable diseases (malaria, HIV/AIDS, TB) (MDG6). More broadly, progress on these indicators will reflect improved provision o f curative, preventive and promotive services and tools (e.g. ITNs), community participation and effective communication for behavior change. Lack of progress will trigger an assessment of which underlying system elements (leadership, humanresources, supply chain management, community participation, etc.) i s or are lagging to permit strategic re-direction o f activities as needed. 3. During the initial phases o f the project (Preparation and Scale-up), activity and supervision reports will be relied uponto track progress of the implementation o f activities, with associated output indicators (e.g. number o f personnel trained, number o f facilities equipped, proportion of planned activities realized, etc.). Periodic surveys that will be planned and implemented will permit assessment of some o f the outcome indicators related to coverage, quality, knowledge and practice that have been proposed for assessing project performance, and the DHSconducted in2005 is beingusedto provide baseline estimates for many ofthese. 44 Tablel. ProjectDevelopmentObjectivesandIndicators(to bedisaggregated:urbankural) Project Outcome Indlcators Useof Project Outcome Information Supportthe strengtheningof %DDS andfacilities receivingtheir Progresson these indicatorswill reflect the healthsystemto budgetina timely manner (to be improvedsectorperformancefor the effectively combat the major specified) provisionandcoverageof curative, communicablediseases and %facilities (by type) with HR preventiveandpromotive servicesand improve access to quality accordingto norms(by type of tools (e.g. ITNs), community services for women, children personnel) participation andeffective andothervulnerable groups % ofbirths attendedby skilled communicationfor behaviorchange. personnel % children 12 to 23 monthsoldwho Change inthese indicatorswill be receivedDPT3beforethe age of 12 Over the Ofthe months project, andprogresswill contributeto % of childrenunder five years of reducingchildmortality(MDG4), age with fever accessing an effective reducing (MDG5) antimalarialwithin 24 hoursof onset andexpanding of symptoms (MDG6). Of % households owningtwo or more T T h T n Lack o fprogressby mid-termreview L l i Y J YOchildrenunder five years ofage will trigger anassessmentofthe who slept under an ITNthe previous underlyingsystemelements that may night be lagging(leadership, financing, YOcaretakers of children under five humanresources, supplychain experiencingillness inthe previous management, communityparticipation, two weeks reportingcost as a barrier etc.) to permit strategicre-emphasiso f supportive activities as needed. 1.1:Strengtheningleadership Id management capacitiesat all levels oj be decentralizedsystem Numberof SteeringCommittee Assess whether regular, monthly Output: Capacityo fMSASF meetingsheld stewardship meetingsare taking for stewardshipandpolicy placebythe committee with development is enhanced authority to influencepolicyand implementationstrategy as well as holdactorsaccountablefor results Output: District Health Number ofDDS/CSSwho submitted Asses the extentto which these Managementsystemsare a costedannual work planaccording critical decentralizedsystem strengthenedfor planning, to the guidelinesby the deadline activities are takingplace budgetinganddelivery of YOofplannedsupervisionmissions quality health services conductedbyNC/DDS/CSSto a decentralizedlevel 45 IntermediateOutcomesand Intermediate Outcomeand Output Use of Intermediate Outcome and outputs Indicators Output Monitoring I.2: Strengthening thefinancial managementandprocurementsystems FinancialManagement I Assess whether financial system Outcome: Health sector funding is made available to budget in a timely manner timely availability of fundingat implement activities FinancialManagement Assess GOC commitment to adequately Output: Health sector funding YOo fthe nationalbudget allocation prioritizing funding it provides to the i s adequately prioritized to health FinancialManagement Output: Capacity built to % CSI/CSS/DDS with staff trained 0Assess implementation o f capacity support decentralized inplanningand budgeting strengthening activities at planning and budgeting decentralized levels Output: Consistent procedures for Procurement % procurement plan activities Assess implementation progress o f the bfgoods and sirvices applied completed per guidelines on time procurement plan 1.3: Strengthening the monitor g and evaluation system Output: Comprehensive M&Esystem for the health sector (that includes regularly % CSI/HR submitting activity reported data, reports on time epidemiological surveillance NumberofDDS who develop and and sentinel site activities, submit trimester reports Lack o fprogress on these indicators periodic household and YOkey indicators (to be specified) will trigger an assessment and facility-based assessments, for which data is available at each redirection o f supportive activities and operations research) level (CSS/DDS/NC) where needed. renderedfunctional to permit % o fEMONB and ECONC facilities strategic, evidence-based conducting direct obstetric maternal management decisions for the and perinatal audits achievement o f project ohiectives Component2: Institution of a efficient and effective systemfor manag g health sector human resources Outcome: An efficient and effective system (recruitment, deployment, refresher courses %facilities (bytype) with HR Assess extent to which implementation and career management) for according to norms (by type o f of HR system activities translates to managing health sector personnel) improvements for service provision human resources i s instituted Output: Health sector human Assess implementation progress o f the resource ulan is imulemented YOplannedHRactivities realized HRsystem plan Component3: Rehabilitation rd equipment of healthfacilities % planned activities relatedto rehabilitation and equipment Output: Implementation o f realized rational comprehensive % facilities (by type) meeting infrastructure rehabilitation physical standards Assess progress related to and equipment plan %facilities (by type) equipped implementation o f the rational supported, as well as a according to norms for PSE rehabilitation, equipment and standardized regular NumberofDDS that utilize the maintenance plan maintenance calendar for maintenance budget according to buildings and equipment plan 46 Intermediate Outcomesand Intermediate Outcome and Output Use of Intermediate Outcome and outputs Indicators Output Monitoring Component4: Improvementof access to apackage of quality essential health 4.1: Define andprovide a PSE Maternal Health Outcome: Improved access to quality % pregnant women receiving full PSE, with special attention to ANC package (Le. 4+ visits, Iron, women, translates to 2+IPT, ITN, TT, etc.) Assess coverage o f key maternal increased coverage o f health YObirths attended by skilled health services associatedwith services and interventions personnel maternal health outcomes (MDG5) associatedwith improved Numberofnew acceptors ofmodem maternal health outcomes contraceptive methods by facility Child Health Outcome: Improvedaccessto quality % children 12 to 23 months old who PSE, with special attention to received DPT3 before the age o f 12 children, translates to months Assess coverage o f these child health increased coverage o f health services associated with child health 0 % children 12 to 59 months who services associatedwith received a Vitamin A supplement in outcomes (MDG4) improved child health the previous 6 months outcomes Malaria Control Outcome: % o f children underfive years o f age Improved access to quality with fever accessing an effective PSE, with special attention to antimalarial within 24 hours o f onset malaria, translates to o f symptoms Assess coverage o f these malaria increased coverage o f health 0 % households owning two or more control interventions (associated with services and interventions ITNs MDG4,5 and 6) associated with malaria 0 % children under five years o fage control and improved health who slept under I T Nthe previous outcomes night HIWAIDS and TB Control Outcome: Increased coverage Assess coverage o f this HIVIAIDS o f health YOpregnant women placed on ARV control intervention (associated with servicesiinterventions according to norms MDG4,5 and 6) associated with HIVIAIDS 0Assess quality and effectiveness o f and TB diseasecontrol and 0 TB cure rate TB treatment services (MDG6) improved health outcomes Output: Improved access to a Numberof facilities offering PSE package o f quality essential Numberof facilities offering VCT for 0Assess progress related to scaling up health services (PSE), with PMTC access to PSE ,with special attention special attention to major CD Number o f facilities implementing to major communicable diseases DOTS strategy 4.2: Strengthen theprocurement and efficient management of essential me 5nes and medical supplies Outcome: Improved supply I chain management o f pharmaceuticals and other YOo f facilities with no stock outs of 0Assess performance o f supply chain health commodities, key medicinesiconsumables (to be management system/ logistics including materials needed specified) during the period (3 management information system for provision o f laboratory months) services I 47 IntermediateOutcomes and IntermediateOutcomeand Output Use of IntermediateOutcomeand outputs Indicators Output Monitoring Outcome: Communities 0 %children 0-23 months o fage with empowered to undertake diarrhea inthe previous 2 weeks who Assess coverage o f appropriate home appropriate care-seeking received ORS or recommended home care behaviors (related to MDG4) behaviors and participate in solution or increased fluids and demandmore and better %motherdcaretakers who know at 0Assess effect o f IEC/BCC activities provision o f health services least 3 danger signs that require consulting a health facility Output: Enhanced accountability o f health % zones, rural quartiers and villages structures and communities with at least one CHW trained, Assess implementation progress o f empowered to participate in possessing a CHW kit and providing scaling-up CHWs service provision and demand more and better care under supervision of CSIs health services I I 4.4: Promote equitable access to quality health servicesfor all Outcome: The importance of 0 % caretakers of children under five Assess extent to which solidarity cost as a barrier to accessing experiencing illness inthe previous measures developed and implemented health services is reduced two weeks reporting cost as a barrier reduce cost as a barrier to accessing to seeking facility-based care health services Output: Equitable access to Track implementation progress quality health services for all NumberofCHWs of indigenous against a plan developed to improve promoted, including for minority groups (pygmies) trained, representation and participation o f indigenous minority groups given a Kit and providing care inthe important minority groups in service (pygmies) 3 DDS over the number planned provision to improve coverage to support basic needs o fthe reorganized system for facilitating Assess implementation o fmeasures poor established and access to health care services by the to facilitate access to health care imdemented I noor services by the poor 48 I 3 m 4 - g cc g d 0 0 3 .2 .t:eE3 m e 2 3 $cw eL F4v E E 3m a"a* Y > .I I .I 9I -2 4 E n n n E E $1 -3 n c'l cu E -- - - ER s 0 n 0 a $1 cu 0 E - En $1 0 d d 2 En n E vi l- - c z c z M .e c $c 0 t 5x c cib * k 4C s f 4El B $% PI PI PI - s g g n m $ $ 0 0 W \o W no\ E g $ $ m W g n s s 0 0 moo E QI m 0 m 3 v, d d $ $ CI m d m o 0 0 - E nE 0 bo C L v1 F4 3c n E n E n E En sm P W E h $ 0 m 0 0 v1 m Y 2v, % N E E n - - E nE z d - L: c, 0 ae a 0 I I r 3 3 0 0 0 0 s g - 0 IC, N 2 2 2 2 6\ u. f 0 0 0 0 g 0 e4 EiEiEiEi IC, s 0 0 0 0 g 0 N 2 2 2 2 IC, 0 0 -0 B .-e MonitoringandEvaluationof Outcomes/Results Overview 4. During project preparation, monitoring and evaluation related activities that must be implemented to support M&E o f PNDS implementation more broadly, and IDA-supported activities more specifically, have been identified and are reflected in the Program o f Work. In line with the phases o f the project (i.e. initiation, scaling-up and consolidation), the first year of the project will support preparatory activities at the central, intermediate and peripheral levels to put in place required elements for effective functioning o f the M&E system (e.g. human resources, supplies and equipment). 5. The conceptual framework o f the monitoring and evaluation system for the sector and the operational plan to be developedwill specify at each level (i.e. community, health facility, health district, health department, etc.) needs in terms o f human resources (including responsibilities and required competencies), supplies, and equipment for the system to function in such as way that all parties, from central level steeringjadvisory committees to decentralized level actors, have timely information they need for making informed planning and implementation-related decisions. The M&E strategy and plan will address the basic components o f an efficient and effective system, including routinely reported health management information, sentinel site surveillance activities, periodic assessments and health system operations research. To strengthenM&E information systems, the M&E strategy andplanwill address information needs by subject (financial, programmatic, etc.) and by type (inputs, processes, outputs, outcomes, impact), specifying information periodicity and bi-directional flow, for key actors at central, intermediate and peripheral levels. 6. The subcomponents o fthe monitoring and evaluation system will include the following: i)routinelyreportedhealthmanagementinformation, includingfacility-basedinformation on service activities, illnesses and deaths, logistics management information related to tracking equipmentand consumables (e.g. pharmaceuticals and bednets), among others; ii)epidemiologic surveillance, particularly for epidemic-prone diseases and sentinel site activities (e.g. tracking illnesseddeaths, insecticide-resistance, treatment efficacy and pharmacovigilance); iii)periodicsurveyassessments,atbothhouseholdandfacilitylevels;and iv) health systems operations research, for example, to identify "best practices." 7. Inaddition, the M&E systemto bestrengthenedwill support periodic updatingofservice delivery maps. Present Monitoring and Evaluation Systemfor the Health Sector 8. As it functions presently, the monitoring and evaluation system o f the health sector in Congo does not comprise all o f the needed subcomponents, particularly with respect to sentinel site surveillance, systematic planning and implementation o f periodic surveys and an operations research program. Further, regarding the health information that i s presently routinely reported, the information flow does not permit needed data to be available ina timely manner at any level 56 o f the system. Major weaknesses o f the current health information system for reporting routine information that have been identifiedduringproject development include: Underreporting: The data transmission flow mirrors that of the current MSASF organogram (April 2008), and as such, the DGS and the Health Departments do not receive any data that i s collected and reported to the Cabinet by certain key health structures, including the University Hospital o f Brazzaville (CHU), the National Blood Transfusion Center (CNTS), the National Laboratory for Blood Transfusion (LNSP) and the Louandjili Hospital. In addition, very few private health facilities and NGOs produce and share information with the health districts inwhich they operate ; Over reporting : The DGS receives information compiled from health departments as well as from the Directorate o f Disease Control (DLM), which can result in an inflated analysis o f some epidemiologic surveillance data, as some o f this data i s reportedto the DGS by both the health departments (who receive it from the CSSs quarterly) and the DLM (who receive it fromthe CSS weekly or monthly) ; Delaved reporting: Even for data reported by structures that are directly under the authority o f the MSASF, desiredcompleteness and timeliness o f reporting are far from being realized. Instruments for data collection and reporting are not standardized, which further renders difficult the compilation and synthesis steps o f the reporting process. At the level o f the CSS, data i s recorded, compiled and reportedmanually (i.e. not computerized). Figure 1: Currentflow of regularlyreportedhealthmanagement information CIRCUITACNEL DE L'INFORMATION f .--* Donnbesperiodiques ... + Rapportannuel __I,Rapportmensuel - ' Rapporttrimestriel I Also o f note i s that at present, the flow o f routinely reported health information i s unidirectional, i.e. it i s only reported up to the central level, -with no feedback or retro- information sharing back down the circuit to the data providers. All o f these weaknesses contribute to the current situation whereby data collected and reported i s not used for decision- makingpurposes at any level. 57 Proposed Monitoring and Evaluation System Strengtheningfor the Health Sector 10. Although the MSASF institutional arrangements are still being finalized, it i s envisaged that a central level monitoring and evaluation service will be placed inthe Directorate o f Studies and Planning (DEP) under the Director o f Administration and Finance. It i s envisaged that this service will be responsible for aggregating and synthesizing data, from all levels o f the health systemon all of the above-mentioned systemcomponents, and for disseminating the information to relevant actors, including to the steering and advisory management committees identified above. 11. Regarding routinely reported health management information, the bi-directional information flow and periodicity of data reporting and aggregation (e.g. between community health workers and health centers (CSIs), CSIs and health districts (CSSs), CSSs and health departments (DDSs), DDSs and central level units, etc.) will be specified in the strategy and plan. Training for not only data collection, aggregation, analysis and dissemination, but also for use for planning purposes, at every level of the system, will be supported. In each of the 12 health departments, andinsome hospitals and health districts, routinely reported information will be computerized. 12. Some work i s already underway to standardize aspects of the routine reporting system, including data recording and reporting forms. For instance, supported by UNFPA and WHO, MSASF is implementinga pilot project inthe Gamboma Health District focusing on improving routinely reported health management informationat the district level. Lessons learned from this pilot will be used to inform the progressive scale-up and expansion of the system to additional districts prior to nation-wide scale-up. Over time as capacity is built, the generated data will be compiled, analyzed and used by M&E units (central, departmental & district) to elaborate quarterly and annual progress reports for dissemination to all stakeholders. However, it is important to recognize that building a system that performs well for reporting complete and timely routine data will take time. As such, information from pilot districts will be used and considered as "sentinel" routine information initially while experience with implementation and strengtheningo fthe routine reporting system is built elsewhere. 13. As previously mentioned, the Program o f Work specifies monitoring and evaluation related activities to support M&E o f PNDS implementationmore broadly and IDA-supported activities more specifically. In addition to supporting preparatory activities at the central, intermediate and peripheral levels to put inplace required elements for effective functioning o f the M&E system (e.g. human resources, supplies and equipment), some additional priority first year activities include: developing the health sector M&E strategy and plan; refining and progressively expanding geographically the health management information system for routinely reported data; involving health departments in adapting and adopting technical directives for epidemic-prone diseases; developing a guidance (or reference) document regarding sentinel sites in Congo to include site selection criteria, activities to be conducted, resources required (financial, human, material); developing an orientation document and establishing a steering committee for the coordination and management o f periodic surveys to address health sector needs; establishing a steering committee for the coordination and management o f operations research anddeveloping a national health sector operations research plan. 58 Management and CoordinationMechanisms and Committeesfor Health Sector Monitoring 14. During project development, the following six groups/committees were identified for management and monitoring o f the sector: i)HealthSectorSteeringCommittee; ii)HealthSectorSteeringCommitteePLUS; iii)HealthSectorTechnicalCommittee; iv) Health Sector Administration and Finance Committee; v) Health Sector Development Group; and vi) Health Sector Review Group. (A complete description o f the role o f each group/committee is detailed in Section I11B o f the main text.) 15. To ensure monitoring o f the implementation of health sector activities and decision- making for effective management of sector resources, the following frequency o f group/committee meetings was proposed: 16. Weekly reviews: The Health Sector Technical Committee will hold weekly meetings to coordinate and discuss technical issues and the Health Sector Administration and Finance Committee will meet weekly to discuss aspects related to the management o f human resources, financial resources and planning. 17. Monthly reviews: The Health Sector Steering Committee will hold monthly meetings to track the functioning and performance o f the sector to discuss and remain informed on actions currently being undertaken in order to propose measures to undertaken to address problems detected. This committee guides policy and implementation strategy o f health sector activities. It has authority for holding implementation actors responsible for results for improving the health o fthe Congolese population. 18. Trimester reviews: The Health Sector Steering Committee PLUS each trimester will meet to review how the sector i s functioning and performing, to discuss actions currently underway and propose solutions to address problems discovered. The Health Sector Development Group will also meet each trimester to exchange information and advice for improving harmonization and coordination o f health sector actors, as well as to advocate for concerted efforts to address financial and/or programmatic gaps identified. 19. Annual Reviews: Near the end o f each calendar year, a review will take place to assess the functioning and performance o fthe system, the level ofprogress achieved and plan activities and budget for the following year, with the implication o f multiple stakeholders. Supervision o f health sector activities will be conducted in the six month interval between annual reviews to focus on technical and programmatic aspects. At the end o f the third year, annual reviews will take place at decentralized levels leading up to the annual National Health Assembly. For example, each CSS will hold its review and elaborate its action plan with the involvement o f the CSIs (and their COSA) and HRs (and their COGES) in their district. The Departmental level annual review and actionplan development will take place with the involvement o f the CSS (and 59 their COGES and CODIR). The annual review and national level action plan development will involve each DDS and their respective COGES and CODIR, among others. At the beginningo f the third year, a mid-term evaluation will take place to assess progress made to date regarding selected performance indicators, and recommendations from this exercise will be used to reinforce progress made and ensure that the project and operationalization o f the PNDS more broadly are on track. 20. As previously mentioned, the M&E health sector strategy and operational plan for the health sector being finalized is taking the information needs o f these groups/committees into account. 60 Annex 4: DetailedProjectDescription REPUBLIC OF CONGO HEALTHSECTOR SERVICESDEVELOPMENT PROJECT 1. The development objective o fthe project is to support the strengthening of the health system in order to effectively combat the major communicable diseases and improve access to quality servicesfor women, children and other vulnerablegroups. 2. The project will obtain this objective through the following three strategic imperatives: 0 Reinforce the capacity o f institutions and managers responsible for reducing maternal mortality, neonatal and child mortality at every level o fthe nationalhealth system ; 0 Improve the provision, quality o f and access to maternal, neonatal and child health services, including family planning ; Reinforce the capacity o f individuals, families, communities and civil society organizations to promote maternal, neonatal and child health, including family planning. 3. More specifically, the project will support o f an integratedjoint program o f work (POW) underpinning a comprehensive sector approach. The POW derives from selected activities inthe following four project components to be accomplished over the next 5 years. 4. Component 1: Strengtheningleadership capacitiesin managing a functioning and decentralized health system. This component will strengthen management and leadership capacities at all levels within the government's decentralization program. The process will involve strengthening capacities in planning and managing sector operations, working within a framework o fpartnership and stakeholder coordination under the following sub-components: Subcomponent 1.1. Capacitv building for leadership and effective management of a decentralized health svstem. Situation analyses will be done and the recommendations used to inform appropriate institutional reforms in the sector through creation o f a new organizational structure o f the Ministry. Specific attention will be placed on capacity buildingfor planning and management o f the sector at all levels, as well as strengthening the coordination o f all stakeholders (communities, NGOs, private sector and external partners). Subcomponent 1.2. Strenathenina fiduciaw systems. Thorough assessment o f the current financial and procurement systems were done and the gaps identified and discussed with the stakeholders. Additional analytical work, including an analysis o f National Health Accounts i s beingundertaken to lay grounds for an MTEF. The project will use the information to strengthen operational capacities for transparent financial management and procurement. Systems will be put inplace to document resource usage at all levels, including government, donor and private sector, and for equitable, efficient and sustainable allocation. Both internal and external audit functions will be developed. Studies will be conducted to identify an appropriate health sector financing system and policy for the Congo by drawing upon ongoing experiences with cost sharing and community "mutuelles." MSASF procurement capabilities at the central, regional and district levels will also be strengthened. 61 Subcomponent 1.3: Strengthening Monitorinn and Evaluation. Through this subcomponent, a monitoring and evaluation system strategy and plan for the sector will be developed and implementedto improvethe availability anduse o fneededinformation by actors at multiple levels o f the system. The strategy and plan will address the basic components o f an efficient and effective system, including routinely reported health management information, sentinel site surveillance activities, periodic assessmentsand health system operations research. An operational plan to refine and support the scale-up o f a national health management information system(for routinely reported information) will be developed andimplemented, buildingon work that has begunon this topic. Epidemiologic surveillance will be strengthened, for epidemic-prone diseases and for supporting sentinel sites activities for tracking illnesses, insecticide-resistance, treatment efficacy and pharmacovigilance, among others. Appropriate planning for periodic household and facility-based survey assessmentswill be ensured, and a healthsystemoperational research planwill be developed and implemented. Finally, support will beprovided for periodic updates o f service delivery maps. 5. Component2: Developmentandimplementationof an institutionof an efficient and effective system for managing health sector human resources (HRH). A baseline HRH database currently being developed will be used to establish a separate HRH Directorate in the central Ministry with specific HR management functions and the technical capacity to create position descriptions and build a repository o f technical fields and professions employed throughout the health sector. The Directorate will also organize a multi-sector consultative framework for working with Ministries o f Education that are responsible for training staff to serve in the MSASF. Under this component, incentives will be created to motivate staff in all areas (e.g. equitable in-service and longer-term training programs, the institution o f more transparent appointments, and performance-based assignment and promotion systems based on merit and requiredcompetencies). A medium-termdevelopment plan for HRHwill be designed and set up.. 6. Component 3: Rehabilitation and equipment of health facilities. An ongoing inventory o f the state o f health facilities will be used as inputs to the design o f how to upgrade facilities, giving priority to the primary healthcare facilities and referral services. IDA will support the mapping and priority and norms/standards setting exercise and will assist the GOC in ensuring rational expenditure o f their resources on phased rehabilitation o f facilities, with special attention to the primary care level: Subcomponent 3.1 Infrastructure rehabilitation, maintenance and construction. Based on the report o f the ongoing inventory, IDA will support the adoption o f a rational comprehensive infrastructure rehabilitation plan and establishment o f a standardized regular maintenance calendar for buildings and equipment. While the GOC and other partners will finance the works, the focus will beplacedon renovation of existingfacilities and new constructionundertaken only inexceptional cases, basedon agreed standards andnorms (prototypes). Subcomponent 3.2 Equipment standardization and maintenance. A full evaluation o f the equipment situation in Congo will be undertaken with IDA support and the information will be used to establish national equipment standards and norms and rational, phased procurement 62 plans. The GOC and other partners will provide the resources for setting up Maintenance workshops and to train bio-engineers to cover every region inthe country. 7. Component 4: Improvement of access to a package of quality essential health services (PSE). This component will comprise four subcomponents andwill receive the bulk of IDAresources: Subcomponent 4.1 Define and provide a Package of Essential Services 1PSE): The PSE has already been definedwill include services for children(IMCI), mothers (Road map), adolescents, and to combat major communicable (Malaria) and non-communicable diseases (Annex 2). Maternal and child health outcomes and malaria will receive special attention. Norms and treatment protocols will be clearly defined and used for training of staff at all levels. Subcomponent 4.2 Strengthen the procurement and efficient management of essential medicines and medical sumlies buildingon the framework already established by the EUunder PASCOB (COMEG). Operational capacity o f COMEG will be strengthened in order to undertake the expanded role o f procurement of all pharmaceuticals and supplies and appropriate financing modalities effected according to the agreement already signed between the Bank, EU and GOC. DPHLM will be strengthened and new structures created to handle pharmaceuticals and decentralized and facility levels. Quality control procedures will be established under this subcomponent. Subcomponent 4.3 Empower communities intheir roles as co-managers of health services. This will be a two way process with both MSASF (supply side) and community (demand side) perspectives. It will entail buildingo f professional capacity within the MSASF and decentralized levels to coordinate government-community partnerships and strengthen community participation inthe management and delivery o f heath services and enhancing effective synergy between PSE and other determinants o f health (water, environmental sanitation, vector management). Community knowledge, participation and support will be strengthened to address maternal and child health and related reproductive health issues. It will also build capacity o f communities to utilize and demand quality services while participating in the management o f health facilities and addressing harmful traditional and social practices through behavior change communication (BCC) campaign. Subcomponent 4.4 Promote equitable access to qualitv health services for all. Activities will include an analysis o f constraints to accessing services among the most vulnerable and poor segments o f the population, and the establishment o f solidarity to support basic needs of the poor. 8. Inthe first year ofthe project, preparatory activities will be carried out at boththe central and departmental levels. There will be a strong focus on completion of preliminary analytical work and setting up management structures such as revised institutional arrangements and various committees responsible for coordination and oversight. During this period, special attention will be paidto fiduciary and stewardship issues. The GOC budget for 2009 will also be prepared and, together with pledges from donors, appropriately aligned to effectively support the annual work plan (AWP). Joint support supervision will be provided, includingthe Annual Joint 63 Review (JAR), to ensure a smooth start and identify implementation bottlenecks. The JAR shall be open and highly participatory in order to `democratize' health, enhance stakeholder participation and ownership by the Congolese. It shall also provide a forum for accountability, assessing progress and retardation against agreed performance indicators at every level, proposing remedies and approving the work plan for next year. Each JAR will be preceded by adequatepreparation, with technical support from external partners. 9. Based on lessons from year 1, the program will be rolled out inthe second year under the strong stewardship o f MSASF.The focus will shift gradually to full and effective delivery o f the Paquet de Services Essential (PSE), including harmonization of activities and donor support and attentionto outputs, relying on a strengthenedM&E system(SNIS). The AWP o f year 2 will pave way for a mid-term review (MTR) to be undertaken early in year 3. The MTR will assess progress against program performance indicators and the recommendations for improving implementationstrategies will for the next phase o fthe project. 64 Annex 5: ProjectCosts REPUBLICOF CONGO HEALTH SECTOR SERVICES DEVELOPMENT PROJECT Project Cost By Component and/or Activity Local Foreign U S $million U S $million Component 1: StrengtheningLeadership capacities inmanaginga functioning anddecentralized Health $1.33 $8.87 $10.20 system Component 2. Institution o f an efficient and effective systemfor managinghealth sector human $0.11 $0.69 $0.80 resources Component 3 : Rehabilitation et equipment of health facilities $0.30 $2.00 Component 4: Improvement o f access to a package o f quality essential health services $3.10 $20.80 $23.90 Total Baseline Cost $4.84 $32.36 Phvsical contingencies $0.10 $0.70 Price Contingencies $0.26 $1.74 $2.00 TotalProjectCosts' $5.20 $34.80 Interest during construction 0 0 Front-endFee 0 0 TotalFinancingRequired $5.20 $34.80 $40.00 65 Annex 6: ImplementationArrangements REPUBLICOF CONGO HEALTHSECTOR SERVICESDEVELOPMENT PROJECT 1. Congo is a stable post conflict country. Although still grappling with significant governance issues, the GOC has shown significant commitment to the social sector and a firm resolve to undertake sector reforms. The collaborative approach is new in Congo but there are valuable lessons from the region that Congo can learn from to avoid repetition o f similar mistakes. The convergence o f a reform minded government, partners ready for harmonization and increasingstate resources offers a unique opportunity for Congo to overhaul the performance o fthe health sector through a systems approach and results focus. 2. The program will be implemented within the MSASF organizational set up with reorganized and strengthened units and not through a separate Project Implementation Unit.The Secretary General MSASF, the Director General o f Health (DGS) and the Director General for Administration and Planning (DGAP) will be overall responsible for implementation including the outputs and quality assurance. They will report directly to the Ministerof Health and will be supported by an effective team o f senior staff and international consultants embedded in the ministry. A detailed `governance' structure is underpreparation, taking into account the planned organizational reforms in MSASF taking place under the guidance o f WHO and as part o f the SWAP preparatory process. The detailed structure will be included in the MOU, including a Ministerial level Management Committee, a technical and administrative Departmental and Directorate level. On the advisory side, there will be a Health Sector Development Group consisting o f external partners and senior government officials (including Finance and other ministries)with sub-groups on selected topics. 66 ' r IGSAF Comntiitiication Professiotmel I I Direction General de la Sank 1- DGRessoiircai et Planification DG.4SF I I I I I D D S 12) I 3. Although all units inthe central and regional services o f MSASF would be strengthened, special reorganization and capacity building work i s programmed for the MSASF departments responsible for Planning and Finance (DEP and DAF) and for human resource development (RHS). This i s in response to the clear risks identified in the procurement and financial management capacity assessments undertaken by IDA. Due to weak systems and capacities, the large amount o f funds involved in the program and the challenges o f accountability, effective financial management and internal control will be a priority. To promote timely implementation, long term technical assistance in the key areas o f financial management and procurement i s being implemented. Procurement o f goods, works and services will be the responsibility o f the Head of the MSASF Procurement Unit, working closely with the Procurement Specialist, the Director o f Finance and Director o f Planning. The Director o f Finance will be responsible for all financial management and accounting matters inMSASF. 4. At present, the MSASF operates a fairly centralized management system, with the Central and Regional Hospitals enjoying significant levels of autonomy. The concept o f Regional and District Health Management Teams is not yet in place although WHO is working on their introduction. Despite the government policy o f decentralization, most managerial, administrative and communications issues have yet to be addressed - and the project will be instrumental infacilitating this process. Devolution to districts will be a major change inthe way 67 in which the sector program is implemented; it will be a major focus of the annual review process. Beneficiary consultation and involvement will be strengthened and made more systematic. 5. The comprehensive approach provides an important vehicle for developing national implementation systems and capacity in a non threatening manner. The establishment and expansion of common implementation systems i s an important feature o f the program and the development o f a SWAP, both to build capacity and to reduce waste on parallel systems and procedures. Joint government/partners annual reviews would provide a viable instrument in reviewing progress towards objectives, sustainability and quality o f services. Reduced compartmentalization o f MSASF units and programs would be achieved through program and unit reforms which shift focus from single disease to a holistic program approach, integrating promotional, preventive and curative services, stronger publidprivate partnership and improved performance-based monitoring and evaluation o f the sector program as a whole. Sector wide accountability would be improved and duplication will be greatly reduced as greater focus i s placedon results regarding quality o f care to targetedpopulation groups. 6. The joint annual reviews will offer opportunities to assess progress towards good governance and enhanced technical performance during the preceding year and plan for the following one. The GOC and partners will agree priority activities to be undertaken and allocations o f resources for the coming year. A smaller review will take place in the off-six months, in February, which will focus more on technical and service related issues. In due course, annual reviews will be introduced at Regional and District levels, leading to an Annual National Health Assembly. 7. Congo does not have many external partners, especially in the health sector. All participating partners have agreed to work under the leadership o f the GOC, and a M O U has beenprepared, with legal support from the UNDP to guide the process. The EU, AFD and the UNagencieshave agreed to the comprehensive sector approach and have supported the GOC in the elaboration o f the POW and a common results framework.. The M O U refers to the POW, overall resource envelope, financing arrangements, coordination and monitoring arrangements including joint annual reviews, and a code o f conduct for partners. Selected studies are being undertaken by the GOC, with technical support from partners, in order to inform the process. This is an important confidence building step that is already providing vital information for realistic planning and linkingresource allocation to outcomes. 8. The PNDS was costed and the GOC allocated US$146,660,001.54 inthe 2008 budget to the health sector, an increase o f over 2% above the previous year. Apart from IDA, other external donors that have committed to support the sector over the next five years include the EU, AFD andthe UNagencies 9. Monitoring and evaluation o f outcomes/results: An efficient and effective monitoring and evaluation system permits key data to be available regarding activity planning and resource allocation (financial, human and material) in a timely manner for decision-making for project implementation based on evidence from all levels o f the health system. The monitoring and evaluation system presently in place for the health sector does not adequately meet this need. Work i s already underway to improve certain aspects o f the system. For instance, supported by 68 UNFPA and WHO, MSASF i s implementing a pilot project in the Gamboma Health District focusing on improving routinely reported health management information at the district level. Lessons learned from this pilot will be usedto inform additional revisions to the present system. Inaddition, an assessment of the information flow for routinely reported data at all levels ofthe system has been made and revisions have been proposed (further detailed in Annex 111). Included in the work plan for the project are activities designed to strengthen not only the routinely reported information, but also sentinel site surveillance, operations research and planning and implementation of periodic surveys (both at the health facility and household levels). Over time as capacity is built, the generated data will be compiled, analyzed andused by M&E units (central, departmental & district) to elaborate quarterly and annual progress reports which will be disseminated to all stakeholders. 10. The detailed structure for monitoring and evaluation o f the program has been prepared, including the indicators and reportingmechanisms and periodicity. Since 2006, the MSASF, in collaboration with partners, undertakes an annual joint review o f the national response to the HIVIAIDS epidemic. Through this experience, the culture o fjoint review i s well implemented in Congo. Annual progress of the project will be monitoredthrough the joint review process, and annual joint work plans and budgets will be developed. As o f the third year o f the project, the joint review will be introduced at the departmental and district level, to be followed by the Annual National Health Assembly. Inbetween the joint annual reviews, a six month supervision mission will be conducted, focusing on technical and service related issues. 11. Congo i s in the process o f major fiduciary reforms, with support from IDA'S Governance Project (Projet du Renforcement des Capacitks de Transparence et de Gouvernance -PRCTG). Public Expenditure Review (PER) i s also underway. The HPIC initiative and the I- PRSP are also being finalized with support from both the Bank and IMF. In this context, the Plan d'Action Gouvernemental sur la Riforme de la gestion des Finances Publiques (PAGGEFP) awaits final approval while Le Comiti Interministkriel de Pilotage de 1'itude sur la rkforme de la gestion des investissements publics i s ready. L 'Obsewatoire concernant la Lutte contre la Corruption has been established and Commission sur les Rkformes de la Gestion des Marchis Publiques i s beinginstituted. 12. A procurement capacity assessment was carried out for MSASF by the Bank. Actions planned to address the deficiencies are included in the program activities and include (i) delineation of fiduciary responsibilities between Finance and Planning Ministries and the sector; (ii)establishing a strong procurement unit and clear policies for the sector; (iii)intensive training o f procurement focal persons (Accounting, Internal Audit and COMEG staff) in the principles andpractice ofpublic procurement; (iv) hiringo f a procurement specialist to mentor key MSASF staff and to assist inprocurement for the initial period o f the project; (v) setting of standards and establishment o f regular reporting requirements; (vi) institutionalization o f annual independent procurement audits; (vii) annual review o f prior review thresholds based on finding of the procurement audits, and; (viii) use o f Bank SBD's until the national procurement system acceptable to the Bank have beendeveloped. 13. The financial management arrangements for the project are designedwith consideration for the country's post-conflict situation. The arrangements aim to facilitate disbursementsand to ensure effective implementation and use of project resources and funds. The financial 69 management Unit of the program, established within the MSASF will be led by a qualified, experienced financial manager supported by an international FM expert selected on a competitive basis. The FMteam will be composed o f civil servants recruitedby the MSASF. The FMUnitwillbe responsible for approvingpayments to contracted service providers, suppliers of equipment and goods, and implementing agents and submitting quarter consolidated unaudited Interim Financial Reports (IFR) and bi- annual audited financial statements to the Bank. The internal audit function o f the program will be under the responsibility o f the "Inspection General des Finances" (IGF). The IGF will assign two experts to carry out the work. The staff o f the IGF will be located at the MSASF and will work together with the Inspection Genkrale des Services du Ministere de la Sante "IGS". The team o f internal auditors will review the financial reports submittedbythe implementingagents and will carry out regular internal audit controls, including verification o f eligibility o f expenditures ex post and physical inspection o f works and goods acquired by the project at the central and departmental levels. The findings o f the internal auditors will be used by the MSASF steering committee to make decisions regarding project implementation and payments and contracts for the various service providers and implementing units. 14. One bank account maintained by the MSASF DAF will be opened in Francs CFA in a commercial bank acceptable to IDA. Disbursement from the IDA grant will be transaction-based (replenishment, reimbursement). Transaction -Based Disbursement Method will be used during at least the first eighteenmonths o f implementation. Thereafter, the option o f using the Report- Based Disbursement method could be considered subject to the quality and timeliness of the consolidated IFR submitted to IDA by the MSASF. The "Cour des Comptes" (the Supreme Audit Institution) was established in 2005 but is not fully operational, and its current staffing arrangements do not allow relying on this institution for external audit purposes. Therefore, a qualified, experienced, and independent auditor (external auditor) will be appointed on approved terms o f reference. The external financial audit, including eligibility o f expenditures and physical inspections, will cover all aspects of project activities and will be carried out on a semester basis at least for the first two years o f the project implementation. Appropriate actions will be taken and diligently followed to address the critical challenges observed during the assessment. Detailed financial management arrangements including the status o f conditions o f effectiveness are presented inAnnex 7. 15. The project's negative environmental impacts will mostly result from: i)the buildingand renovation of health facilities (disruption o f the environment, solid and liquidwastes generation, private land occupation, etc) and, ii)mismanagement of medical wastes at the level o f health care infrastructures. To address potential future impacts, an Environmental and Social Management Framework (ESMF) and Resettlement Policy Framework have been prepared. The ESMF includes an analysis o fnational institutionaland legal framework within which the project will be implemented OP/BP: 4.01 - Environmental assessment and OP/PB 4.12 Involuntary Resettlement. The ESMF will allow project implementers and local communities to progressively monitor any environmental and social impacts, based on a monitoring check-list, and to develop mitigation or compensation measures, on the basis o f clear, precise and operational indicators. 70 Annex 7: FinancialManagementandDisbursementArrangements REPUBLICOF CONGO HEALTHSECTOR SERVICESDEVELOPMENT PROJECT Executivesummary 1. The financial management arrangements for the project have been designed taking into consideration the country's weak PFM system. The arrangements aim to facilitate disbursements and to ensure effective use o f project resources and funds while using the country's own systems to the extent possible. To this end, overall coordination o f the project's financial management aspects will be under the responsibility o f the MSASF. The principal objective o f the project's financial management system will be to support the project in the use of resources to ensure economy, efficiency, and effectiveness in delivering the results required to achieve project objectives. The financial management system must be capable o f producing timely, understandable, relevant, and reliable financial information that enables the project's management to plan, implement, monitor, and assess the project's overall progress toward its objectives. 2. Under the Transparency and Government Capacity Building Project, IDA provides supported to strengthen the country PFM system. However, while remedial measures are being designed and put in place such as the installation o f the Office o f Auditor General, the implementation o f the reform i s very slow and it may takes months before we can see tangible results. 3. Usingthe country's financial management systems is the preferred option for the Bank. Such an option could be applied if the implementing agencies' FM arrangements are acceptable to the Bank and capable o f (i) correctly and completely recording all transactions and balances relating to the project; (ii)facilitating the preparation o f regular, timely and reliable financial statements; (iii)safeguarding the project's assets; and (iv) can be subject to auditing arrangements acceptable to the Bank. In this regard, a Bank team carried out an assessment o f the financial management capacity o f the expected implementing entities in the sector at all levels duringthe preparationof the project. 4. Following this assessment, the Government and its development partners including the Bank recognized that the current country PFM system cannot be fully used for the purpose of implementingthe Congo Health Project. Therefore, based on the findings o f this FM capacity assessment o f the MSASF as well as other existing relevant studies such as the CIFA and the PEFA and PER, it was agreed to rely only on some o f the country PFM systems mainly HR, budgeting, internal auditing arrangements to manage the FM aspects o f the project. IDA FM requirements will be applied for accounting, recording, financial reporting, disbursement and external auditing arrangements. 5. The financial management team o f the project, established at the MSASF will be headed by a qualified, experienced financial director supported by an international FM expert selected on a competitive basis. The FM team assigned to the project will be composed o f civil servants 71 recruited by the MSASF already working in the sector or transferred from other ministries. The FMteam will beresponsible for approving payments to contracted service providers, suppliers of equipment, drugs and goods, and implementing agents and submitting consolidated unaudited InterimFinancial Reports (IFR) sixty days after each quarter and semi-annual audited financial statements to the Bank. The internal audit function of the project will be under the responsibility o f the "Inspection General des Finances" IGF. The IGF will assign two experts to carry out the work. The staff o f the IGF will be located at the MSASF and will work together with the Inspection Gknerale des Services du Ministere de la Sante "IGS". The team of internal auditors will review the financial reports submitted by the implementing agents and carry out regular internal audit controls, includingverification o f eligibility of expenditures ex post and physical inspection of works and goods acquired by the project at the central and departmental levels. The findings o f the internal auditors will be used by the MSASF and the project team to make decisions regarding project implementationand payments and contracts for the various service providers and implementingagents. 6. The amount of the project financing is $40 million, entirely financed by IDA. One designated bank account maintained by the FMteam working on the project at the MSASF will be opened inFrancs CFA ina commercial bank acceptable to IDA. Disbursement from the IDA grant will be transaction-based disbursementmethod. Initial deposit o f CFA 250,000,000 will be deposited inthe bank account by IDA uponproject effectiveness. 7. The "Cour des Comptes" the Supreme Audit Institution was established in2005 but i s not fully operational and its current staffing arrangements do not allow relying on this institutional for external audit purposes. Therefore, a qualified, experienced, and independent auditor (external auditor) will be appointed on approved terms o f reference. The external financial audit, including eligibility o f expenditures and physical inspections, will cover all aspects o f project activities implementedat central and decentralized levels and will be carried out on a semester basis (every six months) at least for the two first years o f the project implementation. Audit reports will be submittedto IDA four months after the end o f each semester. CountryIssues 8. The Republic o f the Congo is gradually emerging from a decade o f political instability, conflict, and mismanagement. The country institutions and economy are weak. Structural reforms have been launched in the areas o f economic governance, public expenditure management, and transparency. The current Transparency and Governance Capacity Building Project financed by the World Bank is helping the country strengthen capacity in public administration and tackle corruption and mismanagement. The integrated fiduciary assessments (Country Financial Accountability Assessment, PEFA, Country Procurement Assessment Report, and Public Expenditure and Financial Accountability) conducted in 2006 and 2007 reports outlined significant public finance management weaknesses-mainly in budgeting preparation and control, accounting, reporting, internal and external controls, and human resources. 9. Although there i s cause for cautious optimism (significant improvements have beenmade inthe areas ofpublic finance management and oil revenuemanagement through IDAproject on 72 transparency and governance support as well as other donors financed-projects), it will take a long time for these reforms to yield substantial improvement inthe management o f public funds. Given the fragility of the fiduciary environment, the only financial management and disbursement arrangements that provide the fiscal and fiduciary safeguards requiredfor projects financed by IDA. Project objectives, description, and costs 10. The development objective o fthe project is to support the strengtheningofthe health systeminorder to effectively combat the major communicable diseases and improve access to quality services for women, children and other vulnerable groups. 11. Itwill have the following four components: Component 1: Strengthening leadership capacities in managing a functioning and decentralized healthsystem: US$ 10.2 million 0 Component 2: Institution o f an efficient and effective system for managing health sector human resources (HRH):US$0.8 million 0 Component 3: Rehabilitation andequipment o f health facilities: US$ 2.3 million 0 Component 4: Improvement o f access to a package o f quality essential health services (PSE): US$23.9 million 0 Unallocated funds are estimated at US$2.8 million. Description o fthe different components i s detailed inannex 4. 12. The total project cost is US$40 million and will be entirely financedby IDA. Institutional arrangements for financial management Financial management assessment of the Ministry of Health: 13. The findings of CFAA and PEFA exercises as well as the FM capacity assessment conducted during the project preparation revealed several capacity shortages in the fields of financial management and procurement within the MoH. These weaknesses include (i) insufficiently qualified staff infinancial management at all levels o f the health system, (ii) staffs weak familiarity with IDA and other donors financed-project procedures for reporting, disbursementarrangements, and auditing; (iii) of accounting system acceptableto IDA and lack lack o f computerized and modern accounting tools at Directorate o f Administration and Finance (DAF) at central and regional levels; (iv) weak internal control and records keeping at DAF and other finances units; (v) lack o f linkages between finance units o f the center, regions and health facilities. Furthermore, the assessment carried out during fiscal year 2006 confirmed the lack o f both an adequate tracking and reporting system and a formal accounting system within line ministries such MSASF. 14. The review o f MSASF financial management performance in terms o f fiduciary compliance and practices revealed some weaknesses. The health component o f the HIV/AIDs 73 project implemented by the MSASF faces significant implementation delays and ineligible expenditures although some improvements were noticed recently. Regardingthe sector, although the audit report of IDA-financed project for the period ended December 31,2006 (due on June 30, 2007) has been submitted on time, the audit opinion on the financial statement o f the HIV/AIDs project was qualified due to significant ineligible expenditures and insufficient supporting documentationo f expenditures. 15. Therefore, the only financial management system acceptable to IDA and the participating donors is the one described below. The current FM arrangements in place within the M o H require significant improvements before it could fully meet the Bank financial management requirements as well as the ones o fthe other donors. The "FM Unit of MSASF 16. It was agreed following the discussions during the project preparation to set up the FM team within the Directorate o f Administration and Finance at the MSASF to manage the fiduciary aspects o f the project. This transitional arrangement i s in line with the expected findings and recommendations of the ongoing institutional arrangements o f the MSASF. It is expected in the future the creation o f a single Finance and Administration Department o f the MSASF. The current option requires strengthening the capacity o f the DEP in term o f staffing, logistical and financial resources to enable this Unitto operate efficiently. 17. The Project Secretariat set up at the MSASF will be the Bank and other donors' main counterpart and focal point. It will oversee the entire project management includingmanagement of the finds and will primarily be responsible for: (i) overseeing implementation; (ii) handling financial and administrativemanagement; (iii) collaborating and coordinating with other relevant entities at central as well as regional coordination units involved inthe project for the successful implementation o f the program; and (iv) liaison with the Bank and other donors.. The FM team o f the project set up at Directorate o f Administration and Finance (at central level) supported by an International Financial Management Expertwill be composed o f (i) Finance Director; (ii) one two Accountants (one for central level and one for decentralized level), (iii) Management one Accountant (working on budget issues) and (iv) one Treasurer (working on disbursement issues). The key local FM staff will be recruited among the civil servant working for the MSASF or will be transferred from other ministries such the MoEFB. The International FM Expert will be recruited to provide technical support for a limited period o f time (no more than 2 years) to the FMteam o f the project team including building capacity o f the other implementingentities and the MSASF as a whole. The TORSo f the mission will provide more details on the scope and responsibilities o f the international expert. Summary risk analysis 18. An effective financial management system is vital for the project because o f the needto deliver services quickly to a wide variety o f stakeholders. The objectives o f the project's financial management system are to: (i)ensure that funds are used only for their intended purposes inan efficient and economical way while implementingagreed activities, (ii) the enable preparation o f accurate and timely financial reports, (iii)ensure that funds are properly managed and flow smoothly, rapidly, adequately, regularly andpredictablyto implementingagencies, (iv) 74 enable project management to monitor the efficient implementation of the project; and (v) safeguard the project's assets and resources. 19. To ensure a strong financial management system, the implementing agencies should have an adequate number and mix o f skilled and experienced staff, the internal control system should ensure the conduct o f an orderly and efficient payment and procurement process, and proper recording and safeguarding o f assets and resources. The accounting system should support the project's requests for fundingand meet its reporting obligations to fund providers including IDA, other donors. The system should also be capable o f providing financial data to measure performance when linked to the outputs of the project. Lastly, an independent,qualified external auditor should be appointed to review the Project's financial statements and internal controls. 20. The risks of lack o f transparency, corruption and misuse o f funds are high inRepublic o f Congo and ensuring fiduciary compliance in Congo remains a major concern. Contrary to all other investment projects, Health Sector Reform and Development Project will be implemented through global approach with relatively use of both country systems and IDA financial management procedures. Moreover, the supervisionby the Bank will be carried out with a mixed team o f FM, procurement, disbursement and M&E colleagues and others partners to verify the proper use o f resources (materiality o f expenditures). The fiduciary arrangements agreed upon with the Borrower include: (i) appropriate financial management system; (ii) an provision o f a financial management team at central level of six individuals and two internal auditors provided by the Inspector General o f Finance (iii)computerized accounting system; (iv) enforcement o f double signature on all payments and withdrawals; (v) FM Procedures Manual; and (vi) semi- annual financial audits covering expenditures incurred at central and decentralized level by private external auditing firms; The FM team as well as the Internal auditors will be supported andtrained by an InternationalFMexpert. 75 Table 1:Risk Assessment and Mitigation Risk Risk RiskMitigatingMeasures Conditionsfor Remarks Rating Incorporated intoProject Effectiveness Design cyw Inherent risk H Country level H The GOC is committed to a N The CFAA and the PEFA report outlined reform program that includes the significant PFM weaknesses at central as strengthening o f the budget well as sector levels: (i) budget classifications, implementation o f formulation and execution, financial a reinforced automated financial reporting, and oversight systems, (ii) weak management system. A new legal linkage between agreed policies, budget framework has been prepared. planning and execution, (iii) lack o f an There are still weaknesses in adequate tracking and reporting system capacity, HR, external audit and and a formal accounting system within the preparation o f accounts. The ministries, (iv) lack o f transparency and ongoing PFM reform financed predictability in public resource under the Governance and management at central government and Capacity Building project will public enterprise levels, and (v) the help strengthen the government insufficientlyqualified staffinthe areas o f fiduciary capacity. financial management. Entitylevel H Relying on a dedicated FM team N The assessmento f the key ministries at the MSASF and use o f IDA F M during the CFAA, PEFA and particularly system requirements is critical for the FMassessment of the MSASF during the mitigation o f fiduciary risk. the preparation ofthis project revealed some internal control weaknesses and an inadequate accounting system, financial reporting system acceptable to IDA and insufficient familiarity o f the staff with IDA procedures for FM, both at central and decentralized levels. Project level S (i) Auditingfunction Internal N The resources o f the projects may not contracted with the Inspection reach all decentralized entities (regions). Generale des Finances; (ii) Some delays inthe reporting system and assignment of two internal auditing due to the weak capacity o f the auditors to the MSASF to work fiduciary team may occur. with the staffof Inspection GCneraledes Services du Ministere de la Santk; (iii) MSASF will adopt measures to strengthen ex-ante and ex-post control o f funds allocated to implementing entities and regional offices o fthe MSASF andIA to ensure proper useo fthe funds; (iv) Recruitment o f an International FMExpert to support the FMteam o f the MSASF; (v) Scope o f audit will include review expenditures incurred at decentralized levels 76 Risk Risk RiskMitigatingMeasures Conditions for Remarks Rating IncorporatedintoProject Effectiveness Design (ym) ControlRisk S Budgeting:(i) S Annual work plan andbudget N The project will be implemented in weak capacity at requiredeach year andapproved regions with weak capacity and could centraland by all partners.The project impede the planning and budgeting decentralized FinancialProceduresManualwill process. They also could impact the entities to define the arrangementsfor submission of reliable budget execution prepareand budgeting, budgetarycontrol and report. The Government may not release it submit accurate the requirementsfor budgeting counterpart in atimely manner. work program revisions.IFRwill provide andbudget; (ii) informationon budgetarycontrol weak budgetary andanalysis of variancesbetween execution and actual andbudget control Accounting: S (i) The projectwill adopt 0) y The key FM team staff and internal policiesand accountingstandards, and (ii)Y auditors will be recruited prior to the procedures,lack accountingproceduresand (iii) Y project effectiveness o f qualifiedFM policieswill be documentedin the (iv) N staffat all levels FMPM. (ii) The FMfunctions (VI N (MSASF andIA will be carriedout by qualified (vi) Y at central and individual civil servant recruited decentralized or assigned on competitivebasis; levels). (iii) FMteam supportedby an InternationalFMexpert ;(iv) installationof a computerized accountingsystem. (v) Training onFM including IDA FM procedureswill be carriedout. (vi) Key FM staffat the MSASF andFMExperton board. Internal S (i) Draft the F MProcedures The implementationof some activities of Control: internal Manualandtrainingon the use of the project inthe peripherywill require control system at the manual prior to project more sophisticatedinternalcontrol levelmaybe activitiesimplementation; system. weak due to (ii)UseoftheInspection weak FM GCnCraledes Finances"IGF" to capacityof IA carryout the internal auditing function. (iii) Joint internal audit mission IGF staff andthe Inspection GCnCrale des Servicesde la SantC ((IGS of the MSASF. )) 77 Risk Risk RiskMitigatingMeasures Conditions for Remarks Rating Incorporatedinto Project Effectiveness Design wm Funds Flow: H (i)Paymentrequestswillbe (9N (i) especiallyforimplementation Funds, misuses o f (ii)Y agencies at decentralized level and the project funds and approved by financial controller (iii)-(viii) N MSASF may not be used in an efficient delays in and the Finance Director prior to and economical way and exclusively for disbursements o f disbursement o f funds to intended purposes. funds to IA and contactors or consultants and (ii) natureofsomeactivitiesfinanced The beneficiaries at decentralized entities and IA. under this project and the limited central and (ii) internalauditorsofthe Two resources o f the government may result in regional level; IGFwill be assigned to cany out delays in the disbursement o f funds to Delays in internal audit function; this agencies and beneficiaries. disbursement o f includes regular physical funds o f other inspection, assessment o f the donors and eligibility o f expenditures government incurred at central and counterpart. decentralized levels and review o f the quarterly IFR. (iii)TheIGFwillprovidetwo experts and one o fthem will be assigned to review expenditures incurred at decentralized level; (iv) A ceiling for expenditures that can be handled at regional level will be set up; (v) Bank accounts will be opened incentral bank office in countryside and use o fthe alternative mechanisms o f transfers. (vii) Financial reporting from regional to central level will be made on a monthly basis; (viii) Donors funds and mainly the government counterpart will be included in the annual budget and proclaimed. Financial S (i) reducedelaysandensure To N A team o fFMcivil servant supported by Reporting: proper financial reporting system, FMexperts will berecruited andtrained inaccurate and a computerized accounting prior to project effectiveness to strengthen delay in system inplace and will be used. their skills and improve their knowledge submission o f (ii) formatagreedbyproject IFR o fIDA FMprocedures (disbursements, IFRat central negotiations. accounting and budgeting). However, the and decentralized (iii) internationalFMexpert An increase o f activities may lead to delays in level. will support the FMteam o fthe submission o fthe project accounts and MSASF and training will be IFR. provided to the team prior to project effectiveness. 78 Risk Risk RiskMitigatingMeasures Conditionsfor Remarks Rating IncorporatedintoProject Effectiveness - Design Auditing:delay S (i)Theproject'sinstitutional (i) CourdesComptesestablishedin The in submissionof arrangementsallow for the 2005 is not hlly operational; audit reportand appointment of adequateexternal (i) The auditingprofessioninRepublic of the scope o fthe auditors. Congo mainlyat government level missionmaynot (ii) Bi-annualauditing (institutionofcontrolsmainlythe "Cour cover des Comptes" needto bestrengthened. expenditures arrangementswill carriedout Internationalauditingstandards are incurredat duringthe first two years ofthe followed inthe industry.Audit reportsare decentralized projectimplementation; generally timely, andmanagementletters level (iii) The TORSandscope ofthe containissuesthat assist managementto audit will bediscussedat ensure the continuingadequacyofthe negotiations; financialmanagementarrangements. (iv) The IGFandthe IGSwill be assignedto carryout regular physicalinspectionsandassess the eligibility of expenditures bothat centralanddecentralized levels ; OverallRisk I H H-High,S-Substantial,M-Moderate,L-Low The Financial Management Action Plan described below has been developed to mitigate the overall financial management risks. Strengths andWeaknesses 21. As noted invarious reports, the country's ongoing PFM reform will strengthen fiduciary practices and compliance and will impose a discipline in executing and controlling budget. The proposed FM arrangement will avoid setting up parallel system for the staffing, budgeting, internal control and internal auditing. 22. The main weaknesses for the FM arrangements of this program include shortage o f qualified accountants and auditors (mainly at decentralized levels), delay in reporting and disbursement, limitedfocus of internal audit and ex-post control. The long process involved in producing reports from regions to the FM team of the MSASF at central level, may delay the timely submission o f financial reports to the Development Partners. Obtaining timely audit reports and timely and relevant financial reports was noted as a problem in most o f the assessmentcarried inthe MSASF by various donors. 79 Table 2: FinancialManagementAction Plan Issue Remedialaction recommended Responsible Completion FM bodytperson date Conditions of effectiveness Staffing (key Employment o f the Finance MSASF BY YES FMTeam Director and the Treasurer o fthe FM effectiveness staff) team o f the project: letter o f assignment o f the two staff signed and they are on board. MSASF YES 0 Employment o f the FMExpert: BY contract signed and Expert on board effectiveness Staffing (i) theTORSofthepositionsof Draft MSAF 2 month after NO (Accountants, two Accountants and Management effectiveness Financial Accountant, and (ii) launch the Dated Controller) selection process ;and (iii) finalize covenants the appointment o f these FM staff Staffing: Training o f the FMstaff (Finance MSASFIIDA 3 months after NO training Director, project Accountants at effectiveness central and decentralized and the Dated Management Accountant and the two covenants InternalAuditors ) assigned to the project completed; Information (i) Acquisition and installationo f MSASF 3 months after NO system accounting software for the project effectiveness accounting and (ii) training o f users completed Dated software covenants Administrativ (i) Preparationthe TORSo f the FM MSASFIIDA BY YES e, Accounting, Procedures manual and (ii) selection effectiveness and Financial o f the consultant and (iii) adoption o f Manual the FMProcedures Manual including the format and content o fthe IFR Internal (i) Draft the TORSo f the Internal MSASFIIGF BY YES auditing Auditor; (ii) Signature o fthe MoU effectiveness betweenthe MSASF and the IGF; (iii) employment and o f the two IGFIMSASF Experts o f the IGF assigned to the MSASF to manage the internalaudit function. External :i)DraftTermsofReferenceforthe MSASF and 3 months after NO financial selection o f the external auditors ;(ii) Cour des effectiveness auditing :xpressions o f interest advertised and ,... Comptes Dated kiii)appointment o fthe external covenants financial auditor completed and :ontract signed 80 Financialand administrativemanagement 23. Upon effectiveness, the overall coordination o f the fiduciary aspects o f the project will be the responsibility o fthe FMteam established at the Ministryo fHealth. Overall responsibilities 24. The Financial Management team of the project will be responsible for all budgeting, accounting, disbursement and audit aspects of the project. Inparticular, it will be responsible for designing and establishing a computerized financial management system, approving disbursement o f funds to implementation agencies, maintaining up-to-date accounting records and ledgers, recording fiduciary transactions for all activities pertainingto the project for which the FMteam of the project is responsible, providing fiduciary reports, submittingaudit reports, and ensuring that a proper internal control system is in place to achieve accountability at all levels. At least three sets o f financial reports will be prepared and consolidated by the FM team o f the project, namely the annual budget o f the project, the quarterly unaudited interim financial reports, and the project financial statements. Administrative, accounting, andfinancia1manual of procedures 25. The accounting systems and policies and administrative (including procurement) and financial procedures employed by the project are documented in the project's Administrative, Accounting, and Financial Manual, which will be used by the project staff as a reference manual; by IDA to assess the acceptability o f the project accounting, reporting, and control systems; and by the auditors to assess the project's accounting systems and controls and to design specific project audit procedures. Specific procedures will be documented for each significant accounting function. They will be written to depict document and transaction flows and will cover the flow o f funds, record keeping and maintenance, the chart o f accounts, formats o f records and books o f account, authorization procedures for transactions, planning and budgeting, financial reports (including formats, linkages with chart of accounts and procedures for reviewing them), and auditing arrangements. The manual will also describe the FM team's organizational chart and administrative and procurement procedures as agreed inschedule 3 o f the Grant Agreement. This FMprocedures manualwill combine the country FMsystemandIDA FMrequirementsto reflect the option made. Planning and budgeting 26. The Republic of Congo budget system is complex, reflecting the fiscal decentralization structure. Budget i s processed at central and decentralized levels. The MSASFbudgetingprocess i s similar to the central budgeting process which usually beginsby issuing the budget preparation note to the Budgetary Institutions. Based on the budget manual, the Budgetary Institutions prepare their budgets in line with the budget ceilings and submit these to MoFB by end o f June o f each fiscal year. The budgets are reviewed at first by MoFB and then by the Council o f Ministers. The final recommended draft budget is sent to parliament around early October and expected to be cleared at the latest by the end ofthe fiscal year. 81 27. For the purposes o f this project, it expected that the budget o f the MSASF will include the estimated IDA and other donors' resources. The FMteam set up at the MSASF will prepare an annual work plan and budget for implementing project activities taking into account the project's objectives. The work plan and budgets will identify the activities to be undertaken and the role of respective parties in implementation. Annual work plans and the budgets will be consolidated into a single document by the FM unit o f the MSASF, which will be submittedto the Minister o f Health for approval, and thereafter to IDA for approval no later than December 30 o f the year proceeding the year the work plan should be implemented. 28. The consolidation will be done after the FM team o f the MSASF ensures through its technical department that the plan and budget meet project objectives and the MSASF budgeting policies. The final recommended draft budget o f the MSASF will be sent to parliament in early September and is expected to be cleared at the latest by the endo f December. The CFAA, PEFA and various reports outlined the need for the budget process to be more transparent and systematic inthe areas o f administration and inter-sectoral allocation, and budget reviews. Staffing of the FM team and Internal audit department in the MSASF at central and decentralized levels. 29. The FMteam o f the project set up at the MSASF in DEP (and thereafter at the Direction Financiere et de la Planzjkation in the new organizational chart) will retain staffing resources that are adequate for the level o f Project operations and activities. This staffing arrangement should be sufficient to maintain accounting records relating to the Project financial transactions, and to prepare the Project's consolidated financial reports and submit the same to IDA. The financial management function will be carried by a team composed o f a competent and experienced Finance Director, who will be in charge of the overall financial management function o f the Project, a Treasurer and two experienced accountants (one o f them will be assigned to record transactions incurred at decentralized level) and a Management Accountant. Due to the weak FM skills identified in the sector, an International FM expert with the appropriate FMqualifications and strong experience and excellent knowledge o f IDA procedures and PFM system, will be recruited on a competitive basis for a period o f two years to assist the project FMteam but also to build the fiduciary capacity o f the MSASF. 30. The team will have the overall FM responsibility including, budgeting, accounting, reporting, disbursementand auditing. Since most o f the FMactivities will be performed outside the MSASF and at decentralized levels, the IA will each hire or assign one dedicated project accountant with the required educational background and experiences. The hiring o f a Finance Director and a Treasurer at MSASF will be conditions o f effectiveness. The proceeds o f the grant may be usedto cover the salaries o f these FM staff. Recordkeeping and maintenance 31. The FM team working on the project will be responsible for maintaining the project's records related to expenditures incurred by the various IA. All accounting documents o f 82 contracted implementingagencies will be kept at their premises and made available upon request duringsupervisionmissions andaudit missions carriedout by internal and external auditors Financial reporting: Unaudited Interim Financial Reports "IFR '' 32. Financial reports will be designed to provide quality and timely information on Project performance to Project management, IDA and other relevant stakeholders. Formats o f the financial reports will be developed and agreed during project negotiation. The quarterly IFR includes the following financial statements: statement of sources o f funds and Projects revenue and uses o f funds; statement of expenditures classified by Project components and or disbursement category (with additional information on expenditure types and implementing agencies as appropriate), showing comparisons with budgets for the reporting quarter and cumulatively for the project life; cash forecast; explanatory notes to the IFR; Designated Account activity statements; The consolidated quarterly IFR will be prepared and submitted to IDAwithin 60 days after the end o feach calendar quarter. 33. On the basis o f financial reports received from the relevant implementing agencies at the central and decentralized levels, the FM team will submit a consolidated IFR to IDA within the timeframe prescribed above (60 days after the end o f each quarter). Each o f the implementing agencies will be responsible to submit regular financial reports to the FM team set up at the MSASF. 34. In compliance with International Accounting Standards and IDA requirements, the Project will produce semi-annual financial statements. These include: (i)a Balance Sheet that shows Assets Liabilities and fund balance; (ii)a Statement of Sources and Uses of Funds showing all the sources o f Project funds, expenditures analyzed by Project component and or category; (iii) a Designated Account Activity Statement; (iv) a Summary o f Withdrawals using SOE, listing individual withdrawal applications by reference number, date and amount; and (v) Notes related to significant accounting policies and accounting standards adopted by management and underlying the preparation of financial statements. The financial statements will be submittedfor audit at the end o f each semester. Integrated Financial Management System: computerizedaccounting system 35. Most of the FM departments of the MSASF at central and decentralized levels are currently using a manual accounting system. For the project to deliver on its objectives, a computerized financial management system will be developed based on software to be acquired by the MSASF. The system should integrate budgeting, operating, and accounting systems to facilitate monitoring and reporting. The formats of periodic reports would be developed and agreed with project management by effectiveness. Since most of the projects in Republic o f Congo use the accounting software TOMPRO, it i s likely that this project acquires and installs the same software. The final arrangements will be discussed and agreed before acquisition and installation o f the software.. Audit arrangements 83 Internal audit: 36. MSASF has an inspection unit named Inspection Gknerale de la SantC but this department experiences significant issues among them the staffing arrangements. The IGS does not have the adequate financial and logistical resources to fulfill its mission. Moreover, the IGS o f the MSASF in its mandate focus mainly o f technical aspects o f the sector. To help ensure proper use o f the project funds, it was agreed to establish an adequate internal audit function within the MSASF. An internal audit function led by the IGF will be established to support the project team and the MSASF. The staff o f the IGF will be located at the MSASF offices. The IGF will assign two Expertsto the MSASF to perform internal audit function together with the staff of the IGS o f the MSASF. The role o f the internal audit team will be to ensure that the project's fiduciary procedures and regulations are adhered to by all the implementingagencies. The selected internal auditors will inspect accountingprocedures usedby the FMteam and other I A s to ensure that they conform to the established procedures. This inspection will cover the verification of expenditures including payments of works and acquisition o f furniture and equipment. The scope o f the internal auditors' mission will also include review o f the quarterly IFR as well as any financial statements submitted to IDA by the FM team at central level and other entities. The Administrative, Accounting, and Financial Manual as well as the terms of reference and the M o U signed between the IGF and the M o H will contain a description o f the roles and responsibilities o f the internal audit department and the arrangements that guarantee the necessary level o f independence. By the end o f the project implementation, it i s expected that the internal audit department o f the MSASF will be fully operational. The Bank FMS team and mainly the international FM expert will provide technical assistance and training to the internal auditors' team to enable them to perform properly their mandate. External financial auditing 37. According to the Constitution, the Auditor General (AG) i s responsible to carry out the audit o f all the financial transactions o f the government and subsidies to the regions. The "Cour des Comptes" the Supreme Audit Institution was established in2005 but i s not fully operational and its current staffing arrangements and capacity o f the core team do not allow relying on this institutional for external audit purposes. Therefore, it was agreed to outsource the external audit function o f this project to a private firm o f qualified auditors. This firm will audit the financial statements of the project semi-annually (every six months) for at least the first two years o f the project. The selection o f the firm will be based on terms o f reference that set forth the scope o f the audit. The MSASFwith support o f the Cour des Comptes will preparethe terms o f reference for the audit and they will be agreed by project effectiveness. The audit firm will be recruited on terms that meet IDA requirementsrelating to independence, qualifications, and experience. The participation o f the Cour des Comptes inthe selection process will be required. The scope o f the audit will cover the activities performed by any entity managing project funds, mainly the FM team and the IA at central and decentralized levels. According to the audit policy o f IDA, the FMteam at the MSASF will prepare consolidated project accounts, which include all the sources from donors and the government and relatedproject expenditures. 38. The semi-annual audited financial statements together with the auditor's report and management letter covering identifiedinternal control and accounting systemweaknesses will be 84 submitted to IDA no latter than four months after the end o f each accounting period. A single audit opinion will be issued with respect to project income and expenditures, special accounts, and the IFR. The report will also include specific controls such as compliance with procurement procedures and IFRrequirements and consistency between financial statements and management reports and field visits. The audit report will thus refer to any incidence of non-compliance and ineligibleexpenditures identifiedduringthe audit mission. Audit Report Due Date Audit report o fongoing PHRD Grant June 30,2008 TF090324 Audit report o fthe ongoingHIV/AIDS and June 30,2008 HealthProject- IDA grant H082 The Project audit reports ByApril 30 and by October 31 o feach year (starting 2009) Closingthe accountabilitycycle: followingup on audit queries 39. The management duties of the FM team and the steering committee will include reviewing audited financial statements and internal and external audit findings. The outsourced internal auditing department will require corrective actions to be taken by the Project team and any other relevant implementing agencies to address any weaknesses in the fiduciary management system or incidence o f non-compliance with procedures. The internal auditing department will also use the results o f the audits inmonitoring the performance o f other agencies at national and regional level. This arrangement is intendedto ensure the satisfactory follow-up o f audit findings. Conclusionof the assessment 40. The recruitment o f qualified and experienced FM staff including the International FM Expert and the use o f the IGF staff to carry out the internal auditing function will enable the establishmento fa financial fiduciary management system for the project that satisfies the Bank's minimum requirements under OP/BP 10.02. The financial management arrangements will be adequate to provide, with reasonableassurance, accurate and timely information requiredby IDA on the project's status. The actions required by grant effectiveness to facilitate the establishment of this system are set out inthe Financial Management Action Plandescribedabove. FinancialCovenants a) IFRs will be prepared on a quarterly basis and, the MSASF will submit the IFRs to the Bank and other donors 60 days after each quarter. b) Semi- Annual audited financial statements (every six months) to be submittedto the Bank and other Donors within four months following the end o f the government fiscal semester; 85 c) Preparation of annual detailed work program and budget (by end o f December every year) Supervisionplan 41. A financial management supervision mission will be conducted over the Project's lifetime. Due to the fiduciary risks associated to this project, more supervision mission's budget will be allocated in order to increase the frequency o f controls. At least three supervision missions with appropriate budget allocation are planned during the first two years o f the project implementation to ensure that adequate and effective financial management systems are set up and maintained for the Project throughout its lifetime. These supervision missions will be carried out together with Procurement Specialists, M&E team and Disbursement colleagues and other donors' team. A SOE review (sample o f transactions) will be carried out regularly during each supervision mission to ensure that expenditures incurred by the Project are eligible for IDA funding. The mission will also rely on the findings of the internal auditing team. The Implementation Status Report (ISR) will include a financial and procurement management rating for the project. Disbursementarrangements and flow of funds Disbursement of funds to MSASF 42. The Government o f Republic of Congo (GoC) and Development Partners (DPs) will agree on the annual budgets and work plans which will comprise the components o f this project for implementation in the year in question. Also, the proportion o f financing between GoC and the DPs will be established each year, and revised as needed. After the initial advance for the remaining period for the current year, the Government will submit on a monthly basis, Withdrawal Applications on a monthly basis. 43. Designated Account: To facilitate project implementation and reduce the volume o f withdrawal applications, a DesignatedAccount denominated in Francs CFA will be opened in a commercial bank on terms and conditions acceptable to IDA. This designated account would finance all eligible project expenditures under the components 1 to 4 and would be maintained by the MSASF through the FM team of the project. The authorized ceiling o f the designated account would be CFA 250.00 million. The amount has been calculated to represent approximately four months o f eligible local project expenditures. 44. The Designated Account will be usedfor all payments less than CFA 41.4 millions o f the deposited amount and replenishment application will be submitted, on a monthly basis. Additional deposits into the designated Account will be made against submission o f withdrawal applications supported by appropriate documents as specified in the Disbursement Letter (DL). The Designated Account will be audited every six months by external auditors acceptable to IDA as part o f the overall project audit. 86 Disbursement methods UponGrant effectiveness, IDA will make an initial advance (using the advance method) from the proceeds of the Grant by depositing it into the borrower's Designated Account (DA). Actual expenditureswill be reimbursed using the reimbursement method (also knownas the Transaction-based method) through submission of Withdrawal Applications and against Statements of Expenditures (SOE) which will be prepared and approved inaccordance with the Financial Management Manual. The reimbursement (or Transaction-based) disbursement method will b e used duringat least the first eighteen months of project implementation. Thereafter, the option to disburse against submission of Interim Financial Report (also known as the Report-based disbursement method) could be considered subject to the quality and timeliness of the consolidated IFRsubmitted to IDAby MSASF. Inthis case, cash forecast for the next six months will be included inthe quarterly IFRs submitted to IDA. 45. The project will also have the option of disbursing the finds through direct payments to third party on contracts above a pre-determined threshold for eligible expenditures will also be available. Withdrawal applications for such payments will be accompanied by relevant records such as copies of the contract, contractors' invoices and appropriate certifications. Another acceptable method of withdrawing proceeds from the IDA grant i s the special commitment method whereby IDA m a y pay amounts to a third party for eligible expenditures under special commitments entered into, inwriting, at the Recipient's request and on terms agreed between the Bank and the Recipient. Local taxes 46. Funds will be disbursed in accordance with Project categories of expenditures, as shown in the development grant agreement. Financing of each category of expenditure will be authorized at 100percent inclusive of taxes. Disbursement of funds to service providers. contractors and suppliers including implementing agencies 47. The FM team set up at the M S A S F will make disbursements to service providers, contractors and suppliers of goods and services for specified activities under Components 1 to 4 o f the Project. Payments will be made in accordance with the modalities specified in the contracts for goods, works and services, and in accordance with Bank procurement guidelines. Disbursements will be made in the respective contract currencies not to exceed the amounts stipulated inthe contract for each respective currency. The FM team will promptlyprovide IDA with signed copies of contracts above the prior review threshold in order to ensure timely payments when withdrawal requests are submitted to IDA. The Lists of Payments enclosed with the withdrawal applications will include the contract number shown on the system "Client Connection," in order to facilitate disbursements. In addition to a review o f supporting documents, the FM team will consider the findings of the internal auditing unit prior to the approval of the payments. Payments to NGOs, Associations or implementing agencies will also be made on the basis of services contracts. The FM team, with the assistance o f the IGF and the IGS, will reserve the right to verify the expenditures incurred under services contract ex-post, 87 andrefunds might be requested for non respect of contractual clauses. Misappropriatedactivities could result inthe suspension of financing to a given entity. Disbursement of funds to the Regional Implementation Support Units 48. The FM team of the project at central level will make disbursements to decentralized entities on the basis of an annual program, budget, and schedule called Work Plan. Disbursements will be made in accordance with agreed schedules. The submission of accountability for previous advances will not be a condition for paying subsequent request for replenishment of the region. However, a quarterly financial report showing the total amount received, the expenditures made classified by category and project components as well as the closing cash balance will be required for transfer of subsequent funds to the regionddepartment. In addition, the internal auditing team will include in its work program regular field visits of regions and decentralized IA to review the eligibility of expenditures incurred at these levels. One of the two experts will b e assigned to work on decentralized expenditures. Appropriate corrective action, including reimbursement of ineligible expenditures and misprocurement or suspension of transfer of funds until the issues are addressed, will b e sought from the M S A S F where such actions are identified as a result of exercises carried out by the internal auditingteam and the Bank staff during supervision missions to verify expenditures and performance. The funds will be transferred inbank accounts opened in a commercial bank acceptable to IDA. To mitigate risks, a low ceiling for expenditures that can be incurredat regional level will b e set up. Uses of statements of expenditure 49. Disbursements for all expenditures should be made against full documentation except for contracts valued at less than $200,000 for works, $150,000 for goods, $100,000 for consulting firms, and $50,000 for individual consultants as well as operating costs, which will be claimed on the basis of statements of expenditure. All supporting documentation for statements of expenditure will be retained at the M S A S F and Regional Implementation Support Units and be readily accessible for periodic review by IDA, supervision missions, and external auditors. 50. A condition of disbursement under each annual work planwill be the notificationby IDA of its approval of the work plan. Table 3: Allocation of IDA grant proceeds (excluding taxes) Total Share of financing Disbursement (timillions) (percent) Componentslcategories Good, works, and services, under 40 100% each approved annual work plan Total 40 100% 88 Annex 8: ProcurementArrangements REPUBLIC OF CONGO HEALTH SECTORSERVICESDEVELOPMENT PROJECT General Procurementenvironment 1. A Country procurement review was conducted in June 2006 and an Inter-ministerial Commission was created with IDA's support to revise the Congo's procurement Code. This assessment has identified major flaws in the country's procurement rules and systems - with outdated procedures and compromised administrative capacity. The current national procurement system as per the Country Procurement Issue Paper (CPIP) lacks sound legal framework, standarddocuments, institutional capacity, and internal controls and appeals mechanisms. 2. Congo i s inthe process o f a major fiduciary reform with support from IDA's Governance project and Public Expenditure Review. The HIPC initiative and I-PRSP are also being finalized. Under the Transparency and Government Capacity Building Project, IDA provides support to jumpstart the stalled procurement reform. However, while remedial measures are beingdesigned including the adoptiono f a new procurement code, the implementationo f the reform is very slow and it may take months before tangible results are observed. 3. While the Government is pursuingthe procurementreform, the Ministryof Health, Social Services and Family Welfare (MSASF) has indicated to IDA its intention that national procurement for the Project will be carried out in accordance with the World Bank's "Guidelines: Procurement under IBRD Loans and IDA Credits" dated May 2004 revised in October 2006; and "Guidelines: Selection and Employment o f Consultants by World Bank Borrowers" dated May 2004 revised in October 2006, and the provisions stipulated in the FinancialAgreement. 4. The MSASF and its partners including the Bank have committed themselves to tighten oversight o f the entire program and to ensure it includes measures to counter the risks o f fraud and corruption such as audits and performance reviews by independent third-party agents (cf. detailed measures below). 5. The general description o f various items under different expenditure categories is provided below. For each contract to be financed by the grant, the different procurement methods or consultant selection methods, the need for prequalification, estimated costs, prior review requirements, and timeframe are agreed betweenthe MSASF and the Bankprogramteam inthe Procurement Plan. The Procurement Plan will be updated at least annually, or as required to reflect actual program implementationneeds and improvements in institutional capacity. 89 Advance contracting and retroactive financing 6. In order to accelerate Project implementation, MSASF has expressed its intention to proceed with the initial steps o f procurement before signing the related Financial Agreement particularly with regardto the selection o f key staff o f the Procurement Unit and selected studies. The procurement procedures, including advertising, will be done in accordance with the Bank's Guidelinesin order for the eventual contracts to be eligible for Bank financing, and the normal review process by the Bank will be followed in accordance with the Procurement Guidelines for Goods andConsultants mentioned above. Advertising 7. A draft General Procurement Notice (GPN) will be preparedduringproject appraisal and will be postedinthe DgMarket and DevelopmentBusiness online, internationalmagazines when deemed necessary and inthe national newspapers after board approval. It shall include contracts under International Competitive Bidding (ICB) and consulting contracts (i.e. estimated to cost $200,000 or more). Specific procurement notices i s required for all goods and works to be procured under ICB and Expression o f Interest (EOI) for all consulting services costing more than US$ 200,000 equivalent or more. All N C B procurement packages for goods and works will be advertised inthe national newspapers. Procurement of Works 8. Works procured under the Project will include construction and rehabilitation o f hospitals, health centers, laboratories, etc. But only a small portion o f the Bank's funds will be used for the procurement o f works since other donors have expressed their willingness to finance major civil works. Contracts estimated to cost more than the equivalent o f US$ 500,000 will be procured using ICB. Contracts estimated to cost US$ 200,000 but less than US$ 500,000 will be procured usingNCB. Small works estimated to cost less than US$ 50,000 equivalent per contract may be procured through price comparison received from at least three contractors inresponse to a written invitation. When it i s the only way to get the works executed, small works estimated to cost less than US$5,000 equivalent per contract may be procuredthrough (a) direct contracting; or (b) force account inaccordance with clauses 3.6,3.7 and 3.8 of the Guidelines. Procurement of Goods 9. Goods procured under the Project will include TB, malaria and HIV/AIDS drugs, reagents, bed nets, vaccines, medical and office equipment, furniture, etc. The procurement o f these goods will be done using ICB and the Bank's SBD (excluding long-lasting treated bed nets that will be procuredthrough LIB). Goods to be financed will be grouped into package o f at least US$200,000 equivalent to be procured through ICB. Contracts for goods that have to be purchased on an annual basis, and for other goods and equipment, available on the local market at a competitive price, with a unit value exceeding US$50,000 equivalent and which cannot be grouped together into packages exceeding US$200,000 equivalent and which are unlikely to be o f interest to foreign suppliersbecause o f their small size and the geographical dispersion o f the 90 delivery points, will be awarded on the basis o f NCB. Goods that cannot be grouped into bid packages o f US$50,000 or more may be procuredusingprudentshoppingprocedures. 10. Procurement o f essential drugs and medical consumables will be done through the national procurement drug agency, a non profit organization named COMEG "Congolaise des Midicaments Essentiels Giniriques", which has started delivering drugs to the MSASF, the HIV/AIDS Project financed by the Bank and the Global Funds. COMEG has been established with the financial support o f EUwhich still provides technical assistance. COMEG will act as a supplier through direct contracting method using its own manual o f procedures that has been found acceptable by donors. The MSASF has currently not the capacity to procure drugs, reagents and medical supplies inan efficient andeconomic manner. Domesticpreference 11. For local contractors i s allowed in the case o f I C B contracts, in accordance with the provisions o f paragraphs 2.55 and 2.56 o f the Procurement Guidelines shall apply to goods manufactured inthe territory o f Recipient and works to be carried out by domestic contractors. NationalCompetitiveBidding(NCB) 12. Advertised locally would be carried out in accordance with procurement procedures acceptable to IDA, provided that the principles o f economy, efficiency, transparency and fair competition and in line with Bank's Guidelines, are respected. For NCB, the following conditions shall be met: (a) the procurement notice shall be advertised on the MSASF website, in the national press or official gazette with wide circulation; (b) methodsusedto evaluate bids and award contracts are known to all bidders and not applied arbitrarily; (c) all biddershave adequate response time (four weeks) to prepare and submit bids; (d) bid evaluation and bidder qualification are clearly specified inbidding documents; (e) no preferential margin is granted to local contractors and manufacturers; (f)bids shall be opened inpublic; (g) no bid can be rejected during the bid opening session; (g) awards are made to the lowest evaluated bidder in accordance with pre-determinedand transparent methods; (h) bid evaluation reports clearly state the reasons for the rejection o f any non-responsive bid and (i) publication o f all procurement processes, bidding and contracts awards on the MSASF website. The above conditions shall be detailed in the Program Implementation Manual (PIM) and/or in the Manual o f Financial, accounting and administrativeprocedures. Selectionof Consultants baseline and various studies; (b) capacity building activities; (c) studies, supervision, support(a) 13. The consultant services under the Project will include the following activities: o f program implementation, financial management and procurement support, financial and procurement audits; and (d) technical matters and training. 14. Consulting firms for all assignments estimated to cost the equivalent o f US$ 100,000 or more will be selected though Quality and Cost Based Selection (QCBS) methodology. For assignments costing less than US$ 100, 000, QCBS or Least-Cost Selection (LCS) procedures 91 may be used provided the assignment meets the requirements o f paragraph 3.6 in the case o f LCS. 15. Consultant services providedby firms estimated to cost less than the equivalent of US$ 100, 000 may be contracted by comparing the qualifications of consultants in accordance with paragraph 3.7 of the Guidelines. 16. Assignments estimated to cost the equivalent of US$ 200,000 or more would be advertised for Expressions of Interest (EOI) in Development Business (UNDB), in DgMarket online and in at least one newspaper of wide national circulation in Congo. Inaddition, E01 for specialized assignments may be advertised in an international newspaper or magazine. In the case of assignments estimated to cost less than US$ 200,000, the assignment will be advertised nationally. 17. Short lists of consultants for services estimated to cost less than US$ 100, 000 equivalents per contract may be composed entirely o f national consultants in accordance with the provisions ofparagraph 2.7 o f the Consultant Guidelines. 18. Consultant for services meeting the requirements o f section V of the consultant guidelines, will be selected, under the provisions for the Selection of Individual Consultants, through comparison o f qualifications among candidates expressing interest inthe assignment or approached directly. Procurementof non-consultingservices 19. The MSASF is also expected to acquire some non-consulting services, such as those required for training events and program information campaigns. Non-Consulting services are likely not to exceed the equivalent of US$50,000 per contract. Procurement of such services will be done using shopping procedures in conformity with the clause 3.5 o f the procurement guidelines. Trainings, Workshops, Seminarsand Conferences 20. Training, workshops, seminars and conferences attendance and study tours will b e carried out o n the basis of approved annual programs that will identify the general framework of training and similar activities for the year, including the nature of trainindstudy tours/workshops, the number of participants, and cost estimates. OperationalCosts 21. Sundry items and other incremental recurring costs which would be financed by the Project would be procured using the program's financial and administrative procedures manual acceptable to the Bank. 92 Implementationof the Project 22. The Project (as well as the overall program) will be implemented by the M S A S F organizational set up with reorganized and strengthened units and not through a separate project Implementation Unit.The General Secretary and the Director General of Resources and Planning (DG/RP)(to be created) will overall be responsible for implementationincludingthe outputs and quality assurance. They will report to the Ministry of Health and will be supported by an effective Secretariat. 23. A Procurement Unit (Unit6 de Passation des March6.s) will be put in place by the M S A S F before effectiveness. A high level Procurement Expert will be internationally recruited before effectiveness to support this Unit during the first two years and to train at least two counterparts appointed by the M S A S F after comparison of CVs. The counterparts will be trained inorder to upgrade their skills inthe evaluation ofbids, and inthe management and monitoring of contracts for works, andprovisions o f goods and services. 24. A Tender Board (Commission des Marchis) will be set up by the MSASF to open the bids and award contracts. This Tender Board will be chaired by the Minister o f Health or hisiher representative and will include a representative of the Ministry of Finances and Ministry of Planning. Bids and proposals will be evaluated by an Evaluation Committee chaired by the Procurement Expert and comprising three to five experts of the sector. Contracts will b e signed by the Ministry of Health or hisiher representative when the amount is over the equivalent of US$lOO,OOO. This overall procurement arrangement has been discussed during appraisal. The Procurement Unit and the Tender Board will be a condition of effectiveness. The Manual of Procedures to b e approved before effectiveness will give all the details on how procurement of this program will be organizedand implemented. Assessment of the agency's capacityto implementprocurement 25. It was not possible to conduct an exhaustive assessment of the procurement capacity of the Procurement Unit since the staff of this entity will be recruitedthrough a competitive process and will include at least one high-level procurement specialist with proven qualifications and experience. This arrangement is necessary in order to mitigate the high level of overall risk associated with procurement work under the program. 93 7 Procurement Risk Assessment and Mitigation Remarks RiskMitigation Measures Rating incorporated in the Program Design Country H The current national procurement The national procurement system level system as per the CPIP lacks sound will not be used. All procurement legal framework, standard documents, will be done inaccordance with institutional capacity, and internal Bank's procurement and selection controls and appeals mechanisms. A Guidelines includingNCB after procurement reform is underway but development o f an appropriate and the implementation o fthe reform is acceptable standard bidding very slow and it may take months document. before tangible results are reached. Ministry H The Ministryhas no previous National procedures will not be level experience with Bank's procedures. used. National procedures based on the A Procurement Unit to manage current Procurement Code are neither procurement will be created by transparent nor efficient. effectiveness as well as a Tender Board at the Ministry level Decentrali H Health Departments have no manual o f At the decentralized level, each zed level procedures. Weak capacity and Health Department will be experience inprocurement. responsible only for the procurement o f small items (workshops, training materials, and other small hngible items) estimated to cost less than US$ 20,000 per contract and included in the annual work plan with a maximum amount o f $100,000 per year. 94 ProcurementManagementActionPlan Issue RemedialActionRecommended DueDate Procurement Unit Setting up a Procurement Unitwithin the MSASF Effectiveness Tender Board Creating a HealthTender Board and an evaluation Effectiveness Committee acceptable to IDA. The performance o f the Tender Board will be monitored and evaluated during the supervision mission. Staffing Recruitment o f an International Procurement Expert and Effectiveness procurement counterparts whose qualifications will be reviewed by the Bank Training Counterparts o fthe Procurement Experts and memberso f Effectiveness the Tender Board will be trained inBank's procurement mocedures. Procurement Submit a procurement plan to IDA Negotiations planning and monitoringand control Financial, accounting Submit a manual of procedures with a detailed section on Effectiveness and administrative procurement arrangements together with standard bidding procedures documents to be used for NCB Transparency Enhanced transparency to include Web, MSASF Website N/A and local publication o f all procurement processes, bidding and contract awards. Bidresponsiveness Pre-bid conference with prospective bidders (mainly for NIA large contracts) shall become an integral part o f the biddingprocess to enhance transparency and bid responsiveness. Compliance with Post-procurement audits o f 100percent o f contracts N/A procedures annually including (i) post-delivery inspection and verification o f completiodinstallation (ii) and decentralized procurement. Decentralized Above the threshold level, decentralized procurement N/A procurement would be subject to internal prior review by the Procurement Unitfor ensuringquality checks. Selection o fNGOs Tightening oversight and recruitment o fNGOs to be NA detailed inthe Manual o f procedures ProcurementPlan 26. A draft detailed procurement plan for the first 18 months of Project implementation and general procurement plan for the entire Project will be prepared by the MSASF and will be discussed during appraisal. The plan will be approved between the Borrower and the program Team at negotiations and will be made available at the Ministry o f Health on its website. It will also be available in the program's database and on the Bank's external website and to other partners. The Procurement Plan will include prior review thresholds and will be updated in agreement with the program Team annually or as required to reflect the actual program implementationneeds and improvements ininstitutional capacity. 95 Publicationof Resultsand Debriefing 27. Publication o f results o f the bidding process will be required for all ICBs, NCBs, and Direct Contracting. Publication should take place as soon as the no objection i s received, except for Direct Contracting and NCB, which may be done quarterly and in a simplified format. For selection of consultants, disclosure of results i s also required. All consultants competing for the assignment will be informed o f the result o f the technical evaluation (number o f points that each firm received) before the opening o f the financial proposals, and at the end of the selection process the results will bepublished. The publication o fresults inselection o f consultants applies to all methods, however for QCBS and Single Source Selection (SSS) the publication may be done quarterly and in a simplified format. The MSASF shall debrief losing bidders/consultants on the reasons why they were not awardedthe contract, if the losing bidders/consultants request explanation. Fraud,Coercionand Corruption 28. The procuring entity as well as Bidders/Suppliers/Contractorsshall observe the highest standard o f ethics during the procurement and execution o f contracts financed under the program in accordance with paragraphs 1.15 & 1.16 of the Procurement Guidelines and paragraphs 1.25 & 1.26ofthe Consultants Guidelines. Frequencyof ProcurementSupervision 29. In addition to the prior review supervision to be carried out from Bank offices and by Procurement Auditors, it i s recommended to have one supervision mission every six months to visit the field to carry out post review ofprocurement actions. ProgramImplementationManual(PIM) 30. The PIMwill definethe role o fthe MSASF, internal organization, operational guidelines, implementation procedures, standard bidding documents, and reporting requirements. It will include a specific procurement section, specific responsibilities for implementation as well as describe procedures for calling bids, selecting consultants, and awarding contracts. The PIMwill be reviewed before negotiations and Bank's comments will be provided to the Borrower. Submission o f the final version o f the P I M to and acceptable to IDA will be a condition o f project effectiveness. 96 Attachment 1 Details of ProcurementArrangementsthat InvolveInternationalCompetition 1. Works, Goods, and Non Consulting Services List o fworks and goods contract packages to be procured: IIUnitsandDistrictHospitals 6 Various equipment for SONUC I 150,000 IICB I No INo IPrior I0812008 ICB Contracts estimated to cost above US$ 500,000 for works and US$ 200,000 for goods per contract and all Direct Contracting will be subject to prior review by the Bank. 2. ConsultingServices (a) List o f consulting assignments with selection methodsand time schedule. I I I I 420,000 QCBS Prior 1012008 10/2010 , I I I 550,000 QCBS Prior 10/2008 1212009 (b) Consultancy services estimated to cost above US$lOO,OOO for firms and US$ 50,000 for individuals per contract, and all single source selection o f consultants (firms and individuals) will be subject to prior review by the Bank. 97 (c) Short lists composed entirely of national consultants: Short lists o f consultants for services estimated to cost less than US$ 100,000 equivalent per contract may be composed entirely o f national consultants in accordance with the provisions o f paragraph 2.7 of the Consultant Guidelines. 98 Annex 9: EconomicandFinancialAnalysis REPUBLICOF CONGO HEALTHSECTORSERVICESDEVELOPMENT PROJECT This annex describes current macro-economic situationinCongo and government contribution to the Health Sector; the health financing situation in Congo; analyzes the economic rationale for implementing the project; andprovides financial and cost benefit analysis of the project. I. CURRENTMACRO-ECONOMICENVIRONMENT AND CENTRAL GOVERNMENT CONTRIBUTION TO THE HEALTHSECTOR 1. Political instability and insecurity, which engulfedthe Republic of Congo over the period 1997-1999, significantly slowed down its economy and impoverisheda substantial number of the population. The impact o f the dismal economic performance resulted in a decline in investment and erosion o f purchasing power o f a large majority o f the population. 2. However,the period 2004-2005 was characterized by end o f arm conflict and a real GDP grow rate o f 4%, attributable largely to favorable international terms o f trade and creation o f peaceful environment inthe country. Since 2005, the Congo has enjoyed favorable terms o f trade due to increases inoil prices and petroleum production as well as good performance of the non- oil sectors (transport, telecommunications, and other services). This has resulted in sound economic growth rates o f 7.9% and7% in2005 and 2006 respectively. 3. Inthe monetarysector, the country hasconsolidated balance ofpayments gains anddebt sustainability. The debt burden has slightly reduced and the current account balance has increased markedly to about 14% o f GDP. 4. Despite this remarkable improvement, oil production still dominates the country's productive sector, accounting for more than 50% of GDP, 70% o f tax revenues and 85% o f exports. Other sectors such as agriculture, livestock, fisheries, represent not more than 5% o f GDP and industryrepresentjust around2%.2 5. InHealthandHIV/AIDSsector, the Government ofCongo (GOC) has demonstratedits commitment to improvingthe health status o f the population by increasing the sector's share o f the national budget. Public spending on health has, therefore, increased significantly in recent years although the percentage o f the national budget allotted to health remains far below the Abuja commitment o f 15%. As shown in Table 1, health and HIV/AIDS's share o f the national budget amounted to US$132.9 million, representing about 6.0%, in 2007. This rose to 7.3% (US$152.5 million) in2008, and is projectedto increase to 11.2% (US$248.4 million)) in2009. * Comitede Lutte Contre la Pauvrete, Secretariat Technique Permanent Final Poverty Reduction Strategy Paper (( )) January 2008. 99 Table 1:Allocationof NationalBudgetby Sector (in CFA billion) 2007 2008 2009 TOTAL 1,202.8 100.00 2,098.7 100.00 2,173.7 100.00 11. DESCRIPTIONOF HEALTHFINANCINGSITUATIONINCONGO 6. This section describes the health financing situation in Congo with respect to three key components o f health financing: (i)resource mobilization; (ii)resource allocation and; (iii) documenting and accounting for health spending. (i)ResourceMobilization(sourcesofrevenueforhealth) 7. In Congo, the central government's budget constitutes the major source of financing o f health care. In 2007, total investmentbudget allocated to health amounted to US$58.9 million, o f which 92.7% was government's contribution and 7.3 % represented external resources. With regardto operational budget, government contribution alone amounted to about US$76.6 million out o f total operational budget o f about US$76.9 million compared to about US$0.34 million from external sources. Table 2 depicts the 2007 investment and operational budgetsrespectively. Table 2: Investmentand OperationalBudget(2007) Operational Investment Budget Sourcesof Financing Budget (US%million) (US%million) Donor grants 4.3 0.3 Government 55.3 77.6 Total 59.7 77.9 100 8. To mobilize resources from alternative sources, the Government o f Congo (GoC) introduced cost recovery, in the form of user charges in 1990. The GoC authorized hospitals to use all funds collected from user charges for their general running expenditures. Today, user charges form a substantial proportion o f funding health services delivery in almost all health facilities across the country. In effect, the hospitals use user fees collected from recipients of healthcare to finance part o f their operational expenditures. The amount o f funds mobilized from user charges varies from hospital to hospital with the large hospitals collecting more revenues than the small ones. For instance, according to the authorities o f HBpital Makelekele in Brazzaville, the hospital mobilizes, on the average, between US$0.46million and US$0.48million per annum from user fees. (ii)ResourceAllocationandExpenditureManagement 9. A major challenge confronting the health sector inCongo is how to allocate andmanage the resource envelop available for health among various levels o fhealth care (primary, secondary and tertiary), directorates o f the Ministryo f Health (MOH), different levels o f the health system (national, regional and district), and different health services and programs. Key factors inhibitingeffective and efficient resource allocation are: (i) complexity andrigidity o fthe public expenditure management system in Congo (see figure 2); (ii) lack of competent staff endowed with budget preparation and execution skills as well as financial management skills in the administration and finance directorates (les DAFs) at central Ministry o f Health, regional health administrations (les DDS), health facilities; and (iii)lack o f coordination among different directorates o f the M O H and different levels o f the health system. a. Budget Execution at Central Ministry of Health 10. In fiscal year 2007, the budget execution rates o f all the directorates o f the MOH were generally low. Table 3 gives the clear picture o f departmental budgetexecution. 11. Available data at the central M O H portend very low execution rates o f the sector's 2007 operational budget, which vary from directorate to directorate. The overall rate o f commitments by the major directorates o fthe Ministrywas 7.3%. There are more disparities inexecution rates among the different directorates. While the Cabinet Affaires Sociales committed 100% o f its budget, the Direction Gknkrale de I'Action Sociale et de la Famille (DGASF) only committed 6.6% o f its allocations duringthe same period. The disparity i s more pronounced with respect to authorization and disbursement rates. For example, while the Cabinet Affaires Sociales had 100% o f its budget authorized and disbursed, the DGASF had only 6.3% o f its budget authorized anddisbursed. 101 Table 3: Ministkre de la SantC, des Affaires Sociales et de la Famille (MSASF) 2007 Operational Budget Execution Source: Ministere de la SantP, des Affaires Sociales et de la Famille b. BudgetExecution at Regional level 12. Prior to 2006, the Regional Health Administrations (les DDS) used to prepare their annual budget proposals detailing their program o f activities and send them to the central MinistryofHealth (MOH). TheM O Hinturnsends the proposals, onbehalfofthe regions, to the Ministry o f Finance, Economy and Budget (MOF) for presentation and discussion. After the MOF has given its consent, the budget proposals are sent to the Council o f Ministers for approval. Once approved, the M O F sends a circular to the M O H authorizing the M O Hto execute the budgetinthe form o f transfers to the regions. 13. In2006, the MOF created les centres de sous-ordonancement, mandated to approve and authorize all regional health budgets. The Regional Health Administrations prepare their annual budget proposals and send them to les centres de sous-ordonnancement with copies to the Administration and Finance Directorate (DAF) o f central M O H for its records. The centres de sous-ordonnuncement organizes budget meetings for review and discussion o f the proposals. When a consensus i s reached, the budget i s sent to the Regional Treasury (Trisor Departemental) for authorization and payment. 14. Despite decentralizing regional budget preparation and execution, the regions still find it difficult to execute their budget. Every year, various Regional Health Administrations send their budget proposals to their respective centres de sous-ordonnancement but they receive little for implementation o f their program o f activities. This underscores the enormous problem o f resource allocation and management facing the entire health sector in Congo. Additionally, the regions (Zesdepartments) do not receive allocations for investment expenditures. Consequently, information and data on regional investmentbudget execution are difficult to come by. 102 c. Budget execution at Health Facility Level 15. Budget execution at health facility levels is also very weak. The execution rate o f operational budgets varies widely from hospital to hospital. The big hospitals such as Centre Hospitalier Universitaire (CHU) de Brazzaville have high level o f execution rates compared to the small hospitals. Figure 2 presents budget executions at different health facilities throughout the country. Figure 1: Budget Execution of Health Facilities (2007) Graphique 1: Executiondu Budget des EtablissernentsSanitaireo (2007) 10,000,000,000 9,000,000.000 8,000.000,000 7.000.000.000 6.000,000.000 5.000.000.000 4.000.000.000 3.000.000,000 2,000,000,000 1,000,000.000 0 MBG CHT CHM GHRP CML CMN SMSParis CMS- COMEG CHU Total Pretoria Soirrce: MSASF 16. With respect to investment budgets, the hospitals do not receive any funds for undertaking investment activities. This situation has put most health facilities in a bad shape. Also, a large number o f hospital equipment are not maintained and replaced. As a result, myriads of hospitals continue to use outmoded equipment for treatments o f various kinds o f illness. (iii)DocumentingandAccountingforHealthSpending 17. Overall, financial management capacity o f employees o f administration and finance directoratehnits at all levels o f the health system i s weak. Many employees (les gestionnaires et les regissezrrs) in charge o f day-to-day financial transactions have no background in accounting and finance. Internal controls (reviews, checks etc.) are extremely weak; and storage, retrieval and general management o f financial records are improperly done and are generally kept manually. Reporting o f financial information within the Ministry and to the Ministry o f Finance and other relevant government agencies i s not done consistently and timely. This situation has seriously affected financial information sharing and data management as a whole. 18. Periodically, upon receipt o f information from the administration and finance directorates (les DAF), the Financial Adviser (Conseiller Financier) o f the Ministry o f Health (MOH) prepares a financial report in excel form. The report covers relevant information on allocations, commitments, authorizations and disbursements o f funds. It must, however, be noted that this 103 report i s to a large extent incomplete and, therefore, does not provide adequate information and data on health expenditures. 19. At health facility level, at the end o f every month, les Recevezirs incharge o f collecting revenues from user fees prepare revenue and expenditure report which is sent through the Cabinet o f the MSASF to the Direction Gbn&aZe du Trisor (DGT) for integration into the general treasury expenditurereport. However, this report i s not regularly sent to the Cabinet for integration into the overall budget execution statement o f the Ministry. As a result, access to health spendingat facility level i s difficult. Figure2: Publicexpendituremanagementsystem L e c i r c u i t d e la d e p e n s e a u C o n g o E n g ~ g ~ m e n l Source: MEFB and MPAT (11)ECONOMICRATIONALEFORIMPLEMENTINGTHE PROJECT 20. The economic justification for implementingthe project is made on the basis o f the need to: (i)improve equity and reduce poverty through investment in health; (ii)harmonize multiplicity o f donor activities in order to significantly decrease management burden; (iii) improve allocative efficiency by strengthening and improving delivery o f Essential Package o f Health Services(PSE). a. The needto improveequityand reducepovertythroughinvestmentinhealth: 21. Ranked as one o f the poorest countries in the world, Congo's position on UNDP's Human Development Index is 139th out o f 177 countries. Table 4 provides core human development indicators o f Congo. 104 Table 4: Core Human Development indicators (2005) iource: UNDP Human Development Report (2007) 22. Regional disparities in poverty are also very wide across the country. As indicated in table 5 below, the incidence o f poverty varies by geographical location with Brazzaville and Pointe-Noire having the lowest poverty indexes than other locations o f the country. Table 5: Poverty Index by geographical location (2005) Incidenceof Share of the poor Poverty ( Y O ) Brazzaville 42.3 24.2 Pointe Noire 33.5 15.5 Other Communities 58.4 6.8 Semi Urban 67.4 9.4 Rural 64.8 44.2 Total 50.7 100 Source: RbpubliqueduCongo, Diagnostique de la Pauvrete, 19 Novembre 2007 23. Congo has a highburden o f disease and morbidity and mortality are attributedlargely to preventable causes. Infectious diseases and maternal and child health problems account for most o f the morbidity in the Republic o f Congo (60% - 900/). In 2006, 55 percent of out-patient consultations in public hospitals in Congo were due to malaria. The average life expectancy in Congo i s only 49 years. Infant mortality rate i s estimated at 75 per 1000 live births andmaternal mortality ratio 781 per 100,000 live births. Food insecurity and malnutrition are major contributing factors to child morbidity and mortality, and account for the high level o f anemia among pregnant women. Estimates o f the country's HIV/AIDS prevalence rate fluctuate around 4.9 % and have remained stagnant for some years although the incidence of TB i s on the rise. Congo's highmorbidity and mortality level suggest that its 3.9 million people are at risk and the country is not on track to achieving the MillenniumDevelopment Goals (MDGs)~. Concept Note o f Health Sector Reform and Development Project (P106851), October, 2007 105 24. The high mortality and morbidity are due to the poor delivery of health services and unacceptably limited human resources capacity. Available statistics show that there i s approximately 6,477 health workers of which 47% are females. Doctor population ratio i s 1 per 9396; midwife per population 1 to 7,737; pharmacist per population ratio i s 1 to 19,952 and nurse per population ratio is 1 to 3,320. 25. Although several factors account for low accessibility and quality o f health care, the most important factor is the low level of budgetary allocations to the health sector. While government allocations to health has increased significantly inrecent years (4% in2004 to 6% in 2007), the percentage o f the national budget allocated to health i s still small, compared to other sectors, and remains far below the Abuja commitment o f 15%. The 2007 sectoral budget allocation is presented infigure 3 below. Figure 3: SectoralAllocations of the National Budget (2007) 56% QSocial Development OEducation Infrastructure 0 Healthand HIWAIDS .Rural Development Governance 0CuturalDevelopment 0IndustrialDevelopment(PME/PMI) Sovreignty Source: MinistPre de I 'Economie, des Finances et du Budget (MEFB) 26. By regional standards, Congo spends less o f its National budget on Health. Table 6 provides regional comparison o f health spending o f selected sub-Saharan African countries in 2005. 106 Table 6: Healthsystems performanceIndicators,Congo 2005 Source: Republiquedu Congo, Diagonostiquede la Pauvrete, 19November2007 27. It is clear from the foregone analysis that additional investment is requiredto improve health services and make it more responsive to the needs of the people o f Congo. More importantly, this investment i s needed to bridge the gap between the health status o f the rich and the poor. As shown in the figure below, the poorest in Congo have the worst health status indicators compared to the richest. Figure4: Comparisonof Infantand Under-MortalitybyWealth Quintile Comparisonof infantand under-five mortatiiybywealth quintiie 120 100 80 mty/ Wnder Five Mortal1 40 20 0 Pwrest Second Average Fourth Richest PopAverage Wealth quintils Source: Congo Demographic and Health Survey (2005) b. The need to harmonize multiplicity of donor activities in order to significantlydecrease managementburden 28. According to the PNDS (p53-56), about 13 donors (9 multilateral and 4 bilateral) are currently operating in the Congolese health sector, including several international NGOs. The increasing number o f donors has, arguably, brought additional resources to the sector. However, 107 donor operations have historically been implemented in fragmented and vertical manner, with every donor outlining its own rules, regulations, and procedures. As a result, health authorities in charge o f project management are extremely overwhelmed with this multiplicity of donor interventions. Bringing all donors under one umbrella will not only increase resources for health but also will significantly strengthenthe health system and enhance health services delivery. It will also allow donors to share ideas and map out common and better strategies for implementing healthprograms at both medium and long-term. c. The need to improve allocative efficiency by strengthening and improving delivery of Package of EssentialServices (PSE) 29. Hitherto, the MSASFhas implemented its programs without prioritizing sector activities. Budget allocations are mainly done based on incremental basis but not on need. More importantly, annual budgetary allocations are extremely centralized (e.g. investmentbudget) and benefitmostly the urban areas, with little consideration for addressing the course o fthe poor. 30. Under the sector program the Government i s expected to finance delivery o f PSE via parallel funding for the first two years, and thereafter common fundingwith donors. This funding mechanism i s expected to benefit the population intwo dimensions: (i) would increase revenue it substantially and ensure effective planning and prioritization o f activities. It would also make funding for health care more predictable and eliminate fragmentation of funding from various vertical programs in the sector. (ii) it would also ensure that expenditures are directed towards programs that benefit the poorest population. As portend inthe following section, the program's emphasis on PSE at primaryhealth care level makes it more equitable and beneficial to the poor. 111.FINANCIAL ANALYSIS 31. This section analyzes the POW in terms o f the overall costing and resource allocation, resource availability, and discusses the financial sustainability o f the project's POW. a. Analysis of resource allocation The project's overall investment over the next five years i s US$661.0 million averaging about US$132 per annum. Approximately 80% o f the overall resources will be invested in the provision of Essential Package o f Health Services (PSE); 0.5% for human resources; 6.8% for rehabilitation and equipment o f health facilities, and 4.3% for health systems strengthening at central, regional and districts levels. The PES resources will increase from 37.6% at the beginningo f the project to 91.3% at end of project. About 53.5% o f the resources allocated to health systems strengthening will be spent at the start o f the project and thereafter decrease annually to about 8.2% at end o f project. During the first year of the project, 4.8% of the total annual resources will be used on human resources development; and it will decrease to 1.0% at end o f project. 4.1% o f total annual resources will be devoted for rehabilitation and equipment o f health facilities during the first year, increasing to 16.4% at year 2 and to 6.8% at end o f project. The analysis in tables 7 and 8 below shows that the POW underscores the project's 108 development o f objective o f improving the health status o f the poor and the vulnerable. Thus, by allocating more resources to PSE the POW ensures allocative efficiency o f resources. Table 7: Resource Allocation andRequirementby Component Year 2008 2009 2010 2011 2012 Total (US% (US$ (US$ (US$ (US% (US% million) million) million) million) million) million) OverallTotal (US%) 131.4 136.0 132.3 132.3 129.0 661.0 Component Essential Package o f Services (PES) I 6.3I 56.6 I 44.3I 47.1 I 72.0I 226.2 I I I I I I Source: Calculatedfrom POW Table 8: ResourceAllocationand Requirementby Component(YO) Government (% annual total ) 80.4I 78.7 I 80.8I 80.8 I 82.9 I 80.7 Partners (% annual total) 19.6I 21.3 I 19.2I 19.2I 17.1 I 19.3 109 b.Analysis of financingand ResourceAvailability: Interms ofresource availability, the analysis inTables 7 above shows that bothgovernment and donor resources are expected to increase from US$131.4 million to US$l32.3million during the second and third years and decrease marginally to US$129.0 million at close of project. The government and donor contributions (including IDA) are projected to amount to US$533.4 million and US$127.7 million respectively at end o f project. At the beginning o f the project the GoC's contribution (excluding salaries) to Health i s US$105.7 million. This figure i s expected to increase annually by 1.2% to about US$106.9 million, assuming government maintains its current levels o f increasing overall resources to the health sector. Over the past few years, the health sector's share o f the national budgethas increased from 4% in2004 to 6% in2007. c. SustainabilityofMSASF and POW Expenditures 32. Overall government spending and sustainability of the POW expenditures: The sustainability of the POW expenditures as well as MSASF spending can best be examined by looking at the sustainability o f overall GoC's spending. As stated in section (i)above the government has shown high commitment by increasing (4% in 2004 to 6% in 2007) the health sector's share o f the national budget. However it i s still insufficient given the magnitude o f the needs o f the health sector. It also falls short o f 15% declaration by African governments inAbuja in 2005. Government will be able to sustain its contribution to the health sector if current macroeconomic environment is maintained: The real GDP is projected to grow by 8.7% in 2008 and to 9.7% in 2009. Overall fiscal balance (excluding grants as % o f GDP) was 8.6% in 2007 and is projected to increase to 12.1% in 2008. Over the past 5 years, inflation has been kept under control ranging from 1.7% in2003 to 2.6% in2007, and is projectedto slightly increase to 3% by end 2008. Government's nondiscretionary expenditures (domestic borrowing) decreased by 4% since 20054. Ifthis trend continues the government will be able to allocate more resources to discretionary expenditures including health, and therefore be able to meet its required contributions to the project. Donor funding and sustainability of POW investments: Sustainability of the POW expenditures will depend on the level o f donor support to the program. As shown in Table 2 above, currently donor contribution to the health sector is very limited; government spendingfar outstrips donor contributions. The POW provides the framework for donor support to finance project activities. So far partners (EU, UNDP, WHO, AFD, UNFPA, UNICEF, Republic o f China) have responded positively. As indicated in table 7 above total donor resources including IDA amount to US$127.6 million (19.3% of overall resource requirements) over the entire periodo f the project. 33. Fiscal decentralization and sustainability of the POW investments: The POW underpinsthe need to strengthen the health system at all levels. However it does not spell out allocationby levels o f care. It would have been better to specify how much is going to strengthen the regions from the resources earmarked for health system strengthening in the POW. The sustainability o f the POW expenditures at the decentralized regional and district levels depends on the extent to which finds flow to primary health facilities, the efficiency o f the regional and Revue du Fonds Monetaire International (FMI)du 11 au 20 Fevrier 2008 110 district level financial management system and the existing allocation mechanism. To ensure smooth flow o f funds to these levels, performance-based allocation mechanisms such as conditional, specific purpose and matching grants that would ensure funds are equitably transferred to the regions and the districts need to be employed. IV. ECONOMIC ANALYSIS OF THE PDSS a. Summary of Cost BenefitAnalysis (CBA) 34. Inorder to determine whether the project is worthwhile, theproject team conducted Cost- Benefit Analysis (CBA) by estimating the equivalent value o f the benefits and costs to the society as a result o f undertaking the project. A CBA is a procedure whereby costs and benefits o f a project are identified, measured, and compared in monetary terms so as to generate net returns to a project's investment. 35. To effectively perform the analysis and to reach a conclusion as to the desirability o f the project, we expressed all aspects o f the project (positive and negative) interms o f a common unit o f measurement, i.e. money. Thus, all the benefits and cost o f the project were measured in terms o f their equivalent money value. In addition, we did not only express the benefits and costs o f the project in terms o f money but also interms o f dollars in a particular time. A dollar available five years from now i s worth less than a dollar available now. This i s because a dollar available now can be invested and earn interest for five years and would be worth more than a dollar infive years. b. Costs and Benefits 36. Costs are the resources used to carry out project activities. They are o f two kinds: (i) direct costs and (ii) indirect costs. Direct costs (e.g. equipment and material costs, maintenance costs, drug and supplies costs, utilities such as power costs, and personnel costs etc) are actual budgeted resources that are allocated to project activities. Indirect costs (the costs to patients waiting for consultation, traveling costs, child care costs etc), also known as opportunity costs, are unbudgeted for resources that are borne by beneficiaries o f the project. They represent withdrawal from the economy that enables the project to be carried out. 37. Benefits are the positive outcomes resulting from implementingthe project. Benefits can be direct or indirect. Direct benefits, which are primarily obtained from project objectives, accrue to the beneficiaries who directly receive the services provided by the project. From the project's objectives, the main targets are women and children. We assumed that women and children who constitute the bulk o f the Congolese population will derive benefits from the project by utilizing the PSE. Indirect benefits have got to do with a change o fbehavior ofthe project's beneficiaries. For example women who participate inthe PSE program have positive attitudinal change toward family planning services. This analysis ignored indirect benefits due to difficulty in measuring them. 111 c. Methodology 38. We measureddirect benefits, that can be easily measured, which accrue to users o f PSE inthe following two ways: 0 The benefit o f avoiding or delaying the health care costs associated with treating diseases addressed in PSE programs. Costs are incurred when treating a disease, and if these costs can be avoided or delayed, they would represent benefits (ie., costs that are never incurred or borne by the beneficiary o f the program and; costs that are delayed into the future) Increased productivity o f a worker plays significant role in hidher everyday life. A worker's productivity reduces when he/she fall sick. Avoiding or delaying the loss o f productivity from morbidity (ie., earnings forgone from lost workdays) related to diseases conditions addressed in PSE constitutes a benefit because it increasesthe worker's earning potential (human capital). e. Monetization of benefits 39. To monetize project benefits, we characterized the costs of health care that can be delayed or avoided as a result o f utilizing the PSE. According to the PNDS, it will cost Congo CFA261,157,156,500 ($650,000,000) in health spending, assuming an exchange rate of CFA450=US$l), over the next five years. The benefits can therefore be valued in monetary terms (dollars) by their non-biased market prices (i.e. medical costs relatedto diseases avoided or delayed). One o f the key assumptions made for this analysis i s that the project interventions over the next five years would save this amount for Congo; and would constitute direct benefits to the users of the PSE. As indicated in paragraph 2 above a dollar available five years from now i s worth less than a dollar available now. This introduces us to the concept o fpresent value. To obtain the benefits associated with project interventions, the savings were discounted with a five percent discount rate. We also took into account factors such as number o f beneficiaries per annum, percentage of mothers and children utilizing PSE, and prevalence rate of PSE related diseases. We usedthe following formula to monetize the benefits: 0 Estimated number o f beneficiaries per annum X % of mothers utilizing PSE X % of children, youthandadolescents utilizing PSEX prevalence rate ofPSE relateddiseases X present value of PSE benefits. Table 7 below summarizes the results o fthe analysis. 112 Table 7: Summary of Cost-Benefit Analysis for PSDSS Project Costs US$ Goods 7,138,438 Consultants & Training 18,458,271 Drugs & Medical Supplies 2,881,200 Operating Costs 220,594 Non Allocated 11.256.497 Marginal excess burden (10%) 4,000,000 Total Cost 44,000,000 DiscountedTotalProjectCost (5% discount rate) 34,474,000 I I I Project Monetized Benefits Estimated annual number o f beneficiaries 652,080 PSE related diseases prevalence rate 3.0% Percent of children, youth and adolescents covered 56.6% Percent of mothers Darticinating inPSE momams. 27.0% Present value of benefits related PSE $5,092,750 Total benefits of avoiding or delaying PSE related diseases $15,224,908,000 Discounted Total Project Benefits (5% discount rate) $11,928,715,000 f. Sensitivity Analysis 40. A sensitivity analysis is the process of varying a model input parameters over a reasonable range (range of uncertainty invalues of model parameters) and observing the relative change inmodel response. To address the uncertainties associated with the assumptions made in the CBA analysis, w e conducted sensitivity analysis by changing thefollowing variables/parameters (i) discount rate; (ii) related disease prevalence rate; and (iii) the PSE the percentage of mothers utilizing PSE. 41. Changes in the discount rate: From table above, project benefits outweigh project costs. A lower discount rate would still increase the project benefits. We changed the discount rate to a higher discount rate (9%) to observe its effects on the N e t Present Value (NPV). The results of the change inthe discount rate are shown inTable 8. 42. Changes in PSE related disease prevalence rate: One of the underlying assumptions inthis analysis is that, the prevalence of diseases that are treatable under the PSE program are true representatives of children, women and the vulnerable group. To address the uncertainties associated with this assumption, w e increased the prevalence rate of diseases treatable under PSE from the 3% to 5% and obtained greater benefits (Table 8). 43. Changes % of mothers using PSE: Taking into account the assumption that mothers using the PSE will continue to use those services after the project, w e altered the percentage of 113 mothersusingthese services and observed that they will use the PSE when the project is closed. The results o fthe sensitivityanalysis are shown inthe Table 8. Table 8: Resultsof sensitivityAnalysis I Variables I NPV Changes inthe discount rate (9%) $9,964,748,000 Changes in PSE related diseases prevalence rate (5%) $16,627,168,000 IChanges in%of mothersusingPSE(29%) I $17,860,949,000 I g. Conclusion 44. From the forgone analysis and the results shown in Table 7 it i s clear that when monetized benefits are compared with costs, the NPV depicts positive results, indicating the project would generate the expected benefits. Additional analyses conducted to address uncertainties in the assumptions made (sensitivity analysis) also provided positive NPVs for all the three variables we altered. Notes andkey assumptions From the PNDS children, youth and adolescents represent 56.6% o f the total population (3, 900,000) o f Congo. It i s assumed that the project, particularly PSE, would cover this percentage. Assume women constitute 27% o f the population; and a PSE related diseases prevalence rate o f 3%. Assume Project target i s 83.6 %( 56.6 + 27%) o f the population. Estimated number o f beneficiaries 83.6% X 3,900,000=3,260,400. Estimated annual beneficiaries i s 3,260,400/5=652,080 From the PNDS health expenditure over the next five years in Congo is $650,000,000. We discounted this figure by multiplying it by 0.7835 discount factor to arrive at the present value o fproject benefits. Assume a social discount (discount rate adjusted by society's preferences for certain outcomes) rate o f 5%. Because part o f the PDSS would be financed by public money, we need to address any distortions caused by the tax system so as not to underestimate project costs. This introduces us to the concept o f marginal excess burden (MEB) (i.e. measuring the incremental welfare costs of raising additional revenue from existing taxes). A 10% marginal excess burdenwas adopted for this analysis. Assume women, children and adolescents/youth who use PSE would continue to use and benefit from its services after the project. 114 The project team decided to use the net present value (NPV) as the appropriate measure ofthe CBA. The project team also excluded indirect benefits in the analysis owing to difficulty in measuring them. It is assumed that the prevalence of the diseases that are treatable under PSE is true representative of the project target (children, women, and the vulnerable). NPV= Discountedtotal benefits -Discountedtotal cost. 115 Annex 10: SafeguardPolicyIssues REPUBLIC OF CONGO HEALTHSECTOR SERVICES DEVELOPMENT PROJECT A. Background 1. The ongoing PLVSS and the proposed HSSDP are based on national HIV/AIDS, health and social policies and strategies contained the Government's HIV/AIDS Strategic Framework (Cadre strutegigue de la Zutte contre le SIDA) and in the National Health Development Plan (PNDS). Global objectives o f the PLVSS and HSSDP are to increase access to quality health services, especially for women, children and vulnerable groups, particularly the country's pygmy population, and to improve health sector HIV/AIDS response capacity and effectiveness. 2. The project PLVSS involves multi-sector activities to combat HIV/AIDS in the case o f the PLVSS and the HSSDP comprises activities for systems strengthening (health facilities rehabilitation, upgrading staff technical and management skills to provide quality essential services and thereby increase the utilization o f available health services, especially by vulnerable and marginalized population groups and instituting improved financial accountability and equity). The two projects involve possible adverse environmental impacts which are being addressed and need to be well-managed. Negative impact on the environment could result from (i) construction and renovation o f health facilities and (ii)inadequate management o f medical wastes within health facilities, especially those managed by private-for-profit health clinics. Potential quarry exploitation for building materials could also cause negative impacts on the environment. 3. Construction and renovation o f health infrastructures can generate biophysical environmental impacts such as erosion, soil and flora degradation and pollution by solid and liquid wastes. These negative impacts occur mainly during the setting o f these infrastructures, the implantation in building sites and exploitation of quarries for building materials. Constructionand renovation o f medical infrastructures might have negative effects ifhiring labor discriminates against local manpower and if purchase price for private lands to be occupied i s inadequate. Temporary risks to populations' health might arise from pollution and physical harm linkedwith works (dust, noise, traffic and labor accidents, etc.). 4. Health facility activities generate several medical wastes which could pose serious hazards to environment andto humans, ifnot managed efficiently. B. Safeguardpolicies 5. As requiredfor any other Bank financed project, these two projects have to comply with the ten (10) Bank's Safeguard Policies as well as OP/BP 17.50 on Public Disclosure, which require, inter alia, that all environmental safeguard documents be made available in-country and at the Info shop before disclosure and approval. 116 6. Safeguard policy issues are relevant to health activities because of the risks that Project support for activities might generate adverse environmental or social impacts. Even in cases where certain individual sub-projects have little or no adverse impacts, they may collectively leadto significant cumulative impacts. C.Environmental and Social Management Framework 7. The Environmental and Social Management Framework (ESMF) o f the PVLSS and the HSSDP guide environmental and social management o f project activities, is in compliance with national legislation and with World Bank Safeguard Policies. The ESMF includes (i) analysis an o f the national institutional and legal framework within which the PLVSS is being implemented and its adequacy for the proposed HSSDP; and (ii) an analysis o f the pertinence o f all World Bank Safeguard Policies for the Project, with special focus on two policies: OP4.01 - Environmental assessment and OP4.12 Involuntary Resettlement. The analysis o f institutional and legal framework indicates that environmental procedures exclude selection process for small size investments. 8. An essential component o f the ESMF is the Screening Process of annual work plans which underlines the environmental norms and standards that currently being applied in the annual work plans (PLVSS) or to be applied to the proposed HSSDP and the environmental evaluation procedures that may be needed, with special emphasis given to measures addressing the requirements of the Safeguard Policies. The ESMF allows project implementers and local communities to monitor in a comprehensive and progressive manner, the environmental and social impacts, based on an agreed monitoring check-list, and to develop mitigation or compensation measures, on the basis o f clear, precise and operational indicators. 117 9. The Environmental and Social Management Plan (ESMP) is presented in tabular form outlining the main categories o f sub-projects, their potential impacts and proposed mitigation measures. The ESMP includes institutional, monitoring, and budgetary responsibility. The final table also includes the cost o f the institutional, technical, training, information and monitoring measures. The costs o f implementing the ESMP o f the Project are estimated as follows: Responsible Cost (CFA) Measures Actions Government institution Development o f maintenance book 5 000 000 Supervision: PFEDGH DGE 10 000 000 SEPKNLS DGS Monitoring and Evaluation o f the ESMF Technical measures (Continuous monitoring, intermediate and Monitoring: final monitoring and evaluation) CHG, DRC, DRE Municipal Services 50 000 000 COSA Evaluation: Independent 20 000 000 Provision for conduction of20 EIA Training staff & partners involved Training inenvironmental and social inPVLSS and management project; Norms o f hygiene and HSSDP security; medical waste management. Population IEC and awareness on environmental issues PFEDGH 40 000 000 awareness during facility development and health CHGDDSiHealth services deliverv activities District Teams TOTAL 200 000 000 10. To ensure effective application o f the ESMF, it has been recommended that chapters on screening, capacity building, environmental and social action plan and budget be included inthe PVLSS and HSSDP ImplementationManuals. D.BiomedicalWaste Management Plan Situation analysis 11. The biomedical waste management in the health facilities under the ongoing HSSDP shows progress, especially in establishment and use o f incinerators, but some deficiencies persist. The major ones are (i)the lack o f adequate plans and/or internal management procedures (technical guidelines); (ii)the inadequacy o f collection, storage and sorting o f biomedical waste from household waste; and (iii)the lack of adequate and regularly-supplied individual protection equipments and inadequate staff skills and behaviors in the biomedical 118 waste management due partly to limited attention by nursingand support staff to waste handling, which sometimes leads to accidents. 12. The biomedical waste management Plan Plan de gestion des DBM 0 Objective 1: To reinforce institutional and legal framework e Objective 2: To inform and increase awareness o f the concerned populations 0 Objective 3: To train health staff and to buildtheir capacities 0 Objective 4: To supply private initiatives and inbiomedicalwaste management 0 Objective 5: To improve waste management within health facilities 0 Objective 6: To support the implementation o f the biomedicalwaste management Plan Priority Actions Plan over 3 years Activities and costs of the Priority Action Plan (PAP) Activities Responsible Costs in CFA Time Source of frame Waste management technical auide IDHG/DGS 5 000 000 1st year Montfordincinerators in50 CSI I SEP/CNSL 100 000 000 lst, 2nd et DHG/DGS and 3rd year 10 000 000 lst, 2nd Project et DHG/DGS and 3rd year Train and aware health staff DGSP/DSC 25 000 000 lst, 2nd year Information and awareness DHG/DGS 15 000 000 lst, 2nd Project materials inhealth facilities vear I Monitoring at national, regional DHG/DGS/ 20 000 000 During Project and local level District project Health Teams Mid-way monitoring and final Consultant Project evaluation Total of costs CFA OP4.12: Social Assessment and Involuntary Settlement. Context 13. Activities plannedunder the HSSDP would likely includesome construction or extension o f health facilities which could entail significant social impact related to displacement o f people 119 and loss o f socioeconomic activities. The present report presents a CPR for any displaced persons defining objectives, principles and procedures determining the land acquisitions and requiredcompensation that mightbe requiredto carry out such facility construction. Legal framework for the Resettlement and agreement with the WB's OP 4.12 14. The land tenure system in Congo i s regulated by Law no9-2004 o f March 26, 2004 on the code of the national land tenure which is supplementedby Law no10-7004 26 the March 2004 which defines the general principles applicable to the land ownership in Congo. Moreover, land ownership provisions stipulated in the land tenure Law no11-2004 o f bearing 26 March 2004 provides procedures for the appropriation o f privately owned land for public use. The analysis, carried out in accordance with the need to comply with the Bank's OP 4.12, identifies significant differences between national laws and private land appropriation procedures. Within the context o f HSSDP any differences between national land tenure laws or compensation provisions and the provisions o fthe Bank's OP 4 12 would require that the latter be applied. Eligibility for Compensation 15. Persons who legally own rights and own title deeds would have formal rights to land and other compensation. Persons who do not have formal rights or title deeds would stay on the land they occupy but could only receive aid for resettlement. Estimation of the Number of affected persons and their needs 16. Physical infrastructure rehabilitation and extension would involve approximately 20 integrated health centers (CSI) which might entail potential resettlement, which could affect about 40 families (about 400 persons). It i s estimated that half o f the sites (10 CSI) might require the acquisition by privately owned land, especially in rural zones. This would cover approximately 2.5 hectares. Evaluation of Goods 17. An Appropriations Commission, coordinated by the Ministry of Land Reforms and Preservation o f Public properties with members from a number o f organizations, includes representatives o f local concerned authorities and affected groups, notably the pygmies and other disadvantaged groups. Registration of Complaints and follow up 18. Reconciliation and Monitoring Commissions have been set up in affected communes to register complaints, oversee resolution o f conflicts and follow up on resettlement compensation. 120 Requirementsfor ImplementationActivities InstitutionsInvolved Responsibilities Ministry ofLand Set up o f Appropriations Commission Reform and 0 Declaration o f Public Use Preservation o f Public 0 Coordinatiodsupervision Property 0 Informationanddissemination 0 Mobilization o f knds for resettlement compensations District Mayor 0 Set up o f Reconciliationand Monitoringcommissions 0 Information and dissemination Department of Social 0 Coordination o f the social aspects of the HSSDP Affairs 0 Interface between HSSDP and MRF /Directorate General for HealthMSASF. Appropriations 0 Evaluation o fbelongings and goods and o fpersons affected Commission 0 Procedure for payment o f compensations 0 Validation o f the process for identifying and evaluating Conciliation and compensation to be paid. Follow up 0 Registration o f complaints and counter claims Commissions 0 Payments inaccordance with conflict resolutionprocedures. 0 Close monitoring o f the process ineach district and commune. Social Science 0 Socio-economic studies Consultants 0 Evaluation of stages, at midterm and final Estimationof TotalResettlementCosts I Totalcost (CFA) 1 Sensitization o f L _____- _ _ . _ _ I I Monthly follow up 5 000 000 Evaluation (compensation (other personal belongings, foodstuffs I 5 000 000 121 OP4.10: IndigenousPeople's PlanningFramework(IPPF) 19. The Health sector project i s countrywide and includes support for the Pygmies. OP 4.10 has therefore been triggeredand an IPPF prepared. 20. The Pygmies were the first settlers in Congo and reside mainly in three Departments - Likuala, Sangha and Cuvette. They reside in rural forested areas where health care access i s poor. There i s general lack o f health infrastructure in these departments, and the Pygmies rely predominantly on Traditional Medicine. Although specific data on Pygmies i s lacking, the Demographic Health Survey (2005) confirmed higher maternal and child mortality inrural areas. This and the very low literacy levels and poor access to health services point to higher mortality rates among Pygmies than in the rest o f the population. They are also more vulnerable to most common diseases and have a shorter life expectancy. HN/AIDS i s not yet an epidemic amongst the Pygmies, and the people lining with HN/AIDS is supporting prevention activities. In addition, the Ministry o f Health (MSASF) i s currently organizing outreach activities, supported by specific disease initiatives. For example, leprosy i s more common in Pygmies leading to a special focus on this population by the national program. This project intends to build on existing interventions in order to expand access to quality o f services and reduce morbidity and mortality in this group. The PSE will be specially adapted to suit their special circumstances, with emphasis on voluntary participation, ownership and sensitivityto local cultures. 21. Inthis project, the Pygmies are identified as potentially vulnerable and therefore given special attention in the planned interventions. This i s in line with the Government o f Congo's policy to promote their issues and respect their rights within the Congolese society. A draft law for Pygmy protection and integration is under discussion in Parliament. The PDO specifically targets vulnerable groups and takes this to the next steps inSub- Component 4.4 whose objective i s to ensure equitable access to services to vulnerable and undeserved groups, especially the Pygmies, women and children. As part o f the project, a study i s planned to identify barriers to service delivery, participation and equity for these groups, including the Pygmies. The findings will strengthen delivery o f effective interventions for the Pygmies. Sub-Component 4.3 aims to build local ownership and community participation in delivery o f services. Under this component, local NGOs working with the Pygmies, and with support from UNICEF, will be contracted to build the capacity o f the Pygmies to participate in articulating their special needs. This will include rehabilitation of health facilities, establishment o f outreach services and strengthening o f prevention programs, health education and behavior change communication. Finally, the project has identified specific indicators that will be monitored on a continuous basis by the MSASF's M&Eunit and specific Departmental Management teams to inform on progress among the Pygmies and other vulnerable groups. 22. Duringproject preparation, consultations were heldwith UNICEF and groups o f NGOs (Medicenes Afrique) that are already working with Pygmies. UNICEF i s the lead agency on Pygmies and health in Congo and the project will work closely with them. They had prepared a document on Pygmies health. These were followed by special meeting with Pygmy groups inthe three Departments, building on the process that had been initiated under the HIV/AIDS and Health Project. Some o f the concerns addressed included Pygmy inclusion in decision making during project planning and execution, identification of change agents among Pygmies, 122 utilization of schools as an entry points for health education, training of Pygmy community health workers as part of the Community subcomponent and provision o f health care, especially M C H to mobile groups. The concerns are addressed in the project design, especially in component 4. Activities Responsible Costs in CFA Time I Indicator frame Rapid assessment o f Pygmies MSASFIDD 10 000 000 1st year Assessment health status and access to SIDGAS report services aide Consultations with Pygmy M SASFIDD 50 000 000 Appraisal, Consultation communities S/DGAS/Pre & reports and fects Annually consensus Capacity buildingo f Pygmy MSASFIDD 100 000 000 lst, 2nd # o f leaders leaders and Health SIDGAS and 3rd and groups committees year trained TrainingofPygmy MSASFIDD 100 000 000 lst, 2nd # Pygmy C H W Community HealthWorkers SIDGAS year trained (CHW) Development o f IEC and MSASFIDD 50 000 000 lst, 2nd # IECIBCC BCC materials for Pygmies SIDGAS year materials on PSE developed Monitoring at national, MSASFIDD 20 000 000 During Project regional and local level SIDGAS project Mid-termmonitoring and Consultant 10 000 000 3rd and 5th Project final evaluation year Totalof costs 340 000 000 (CFA) 123 Annex 11:ProjectPreparationand Supervision REPUBLIC OF CONGO HEALTH SECTOR SERVICESDEVELOPMENTPROJECT Planned Actual PCNreview 11/08/07 11/08/07 Initial PID to PIC 01111/08 01111/08 Initial ISDS to PIC 01114/08 01114/08 Pre-Appraisal 12/03/07 12/03/07 Appraisal 03/10/08 03/10/08 Negotiations 04121/08 BoardAZVP approval 05/29/08 Planned date o f effectiveness 08/20/08 Planned date o f mid-termreview 07/15/10 Planned closing date 05/29/12 Key institutions responsible for preparationofthe project: MinistryofHealth and Ministryo f Finances andPlanning Bank staff and consultants who worked on the project included: Name Title Unit Khama Rogo Task Team Leader, Lead Health Specialist AFTH3 Mahamat Goadi Louani Sr. HumanDevelopment Specialist AFCCG Bienvenu Biyoudi Economist AFCMG Adrien Dozol Jr. Professional Officer HDNHE Stefanie U.S. Brackmann Safeguards Specialist AFTEN Nicolette K.Dewitt LeadCounsel LEGAF Melisse ElizabethMurray Sr. Public Health Specialist/ETC AFTHD Luc Lapointe Procurement Specialist AFTPC Maurice Adoni Procurement Specialist AFTPC Jean-CharlesAmon-Kra Sr. Financial Management Specialist AFTFM Mohamed Kamil Sr. Public Health Consultant AFTH3 Michael Azefor Sr. Public Health Consultant AFTH3 Kofi Amponsah Health Economist Consultant AFTH3 Prosper Biabo Management Consultant AFTH3 Amadou Konare Sr. Environmental Specialist AFTEN Yasmin Tayyab Sr. Social Development Specialist AFTCS Dieudonne NdumbiKatende InformationAnalyst AFRIT Clementine Maoungou Public InformationAssistant AFREX Prof. Therese Kinkela Nutrition Consultant HDNHE Dr.Harry Osore Nutrition Consultant HDNHE JosyaneCosta Team Assistant AFMCG Astania Kamau Language Program Assistant AFTH3 Bank funds expended to date on project preparation: 1. Bank resources: $ 75,000 2. Trust funds: $0 3. Total: $75,000 Estimated Approval and Supervision costs: 1. Remainingcosts to approval: $30,000 2. Estimated annual supervision cost: $50,000 124 Annex 12: Documentsinthe ProjectFile REPUBLICOF CONGO HEALTH SECTOR SERVICESDEVELOPMENT PROJECT 0 PlanNational de Developpement Sanitaire 2007-2011 Instructions et directives techniques pour la mise en Oeuvre des paquets de services essentiels (draft October 24,2007) Plan Stratkgique de Lutte contre le Paludisme 2008-2012 (juin2007) 0 Politique National de Lutte Contre le Paludisme au Congo (fkvrier 2006) PlanNational pour l'atteinte des OMG au Congo (Draft 3) 0 Feuille de RouteNationale pour accClCrer la reduction de la mortalitti maternelle, neonatale et infantile Plan Stratkgique de Lutte contre la tuberculose au Congo 2008-2012 (juin2007) 0 Plan Pluri Annuel Complet du Programme Elargide Vaccination 2008 -20 11 (septembre 2007) Plan Stratkgique 2005-2009 PCIME Congo (janvier 2005) Proposition au Fonds Mondial SCrie 7 :Tuberculose et Paludisme (juillet 2007) Rapport d'Activitts du Programme Elargi de Vaccination Annee 2006 (dkcembre 2006) 0 Plannational de preparation et de riposte aux urgences Cpidkmiques au Congo 2008-2010 (decembre 2007) Projet d'Elimination de la schistosomiase en 5 ans par approche communautaire et plurisectorielle au Congo (2005) Guide Techniquepour la Surveillance Intkgrkedes Maladies au Congo (draft) Exemplaires des supports de collecte des donnkes SIS pour Gambona (fourni par 1'UNFPA) Rapport Annuel Programme de LutteContre 1'Onchocercose 2007 (decembre 2007) Situation actuelle de la lutte contre l'onchocercose au Congo (presentation 2007) Politique nationale de sante du Congo, 2003 DCcret 2007/303 du 14juin 2007 relatif aux attributions du Ministre de la sante des Affaires Sociales et de la Famille Rapport synthese de l'analyse participative de l'organisation et du fonctionnement du Ministere de la Santk, 2 novembre 2007. 0 Dkcret 2000/107 portant reglementgeneral de la comptabilite publique 0 Loi no01 - 2000 du l k r fkvrier 2000 portant loi organique relative au regime financier de 1'Etat. 0 DCcret 98/256 du 16juillet 1998, portant attribution et organisation de la Direction gknkrale de la santC 0The Choice of FinalAids Instruments,OD1, October 2001,Working Paper 0 SWAP: A Resource Document for UNFPA Staff, HLSP Institute, September 2005 CIDA: Primer on Program-Based Approaches, February 17,2003 Congo : PlanNational de Suivi et Evaluation 0Guideto SWAP for Health Development: Concepts, Issues andworking arrangements (Andrew Cassels) 0Budgetd'investissement: RCpubliquedu Congo, Exercice 2007 125 0 Congo : Budget de Fonctionnement : Transfert. Ministkre de Santk, Affaires Sociales et Famille 0 Budget d'Investissement, Transfert: Rkpublique du Congo, Exercice 2007 0 Rkpublique du Congo : Budget de l'Etat, Exercice 2007, Loi des FinancesNo. 4 - 2007 du 11mai2007 0 Dkcret No. 98-256 du 16-7-2007, portant attributions et organisationsde la DG de la Sante, Annexe 2 0 Dkcret No 2003-167 du 8 aoQt 2003 portant organisation duMinisthe de la SantC et de la Population 0 Documentde formulation de projet : Projet de RenforcementInstitutionnel et d'Appui au secteur de la Santk (December 7,2005) 0 Congo Programmede Coopkration2004-2004. Plancadre opkrations (Novembre 2002), UNICEF 0 Ghana : SecondHealthPopulation Project, Health Sector SupportProject, Project PerformanceAssessment (WB/ IEG) 0 Ajoint programofWork for Health Sector Wide Approach (SWAP), 2004-2010, Republic of Malawi, March2004 0 StrengtheningHealth Systems to Improve Health Outcomes, WHO'SFramework for Actions, 2007 0 Governmentof Congo :PTRCG :Manuel d'ExCcution et ProceduresAdministratives, July 2001 0 Costab : PLNLS Congo, 2004 0 PNLT :Couts unitaires 0 PNLT :Tables Financieresde synthese 0 PNLT : Plan d'action 0 Congo : MSASF :fiche Technique, 9 mai 2007 0 Nations Unies : mkmorandum sur les fiais de mission, 9 mai2007 0 Congo : PNLS - Estimation des coats unitaires 0 UNDP :Universal price list, 2007 0 Budget de l'klaboration du PURHS, 2007-2008 0 Plan d'action PLUSS 2006 0 PRTGC : Coat estimatif des Skminaires 7/6/2006 0 PRTCG :Tableau d'klaboration budgktaire, 7/6/2006 0 WHO :Price List - Catalogue 2007 0 Fonds Mondial :Medecines price lists 0 WHO : Ordering procedures 2007 0 WHO :price lists for ARV 0 WHO :Work Plan, detailed Budget 0 Congo :plannational de preparation et de riposte des urgenceskpidkmiques, 2006 -2010, Dkcembre 2007 0 Termes de rkference :Elaboration des comptes nationaux de la santk -2005 -2006 0 Improvingthe life quality of Indigenous People(pygmies) inthe Republic of Congo: Project Proposal, Brazzaville, (February 22,2008) 126 BanqueAfricaine de Developpement et Fonds Africain de Developpement :Dkpartement des Operations Pays-Region Centre (Dkcembre 2007). Rkpublique du Congo :Documentde stratkgie par pays axee sur les rksultats (DSPAR 2008-2012) MSASF/Congo et UNICEF (Juin 2007). Analyse de la situation des enfants et des femmes autochtones au Congo Conseil Nationalde Lutte Contre le SIDA, Republiquedu Congo (prepare avec l'assistance technique de MACRO-International (Sept 2007). Plan de travail, protocole et budget de l'enquete de seroprkvalenceet sur les Indicateurs du SIDA au Congo (ESIS 2008) Conseil Nationalde Lutte Contre le SIDA, Republiquedu Congo (Mars 2008). Rapport annuel de suivi et evaluation de la reponse nationale au VIH/SIDA (Janvier -DCcembre 2007) 127 Annex 13: Statementof Loansand Credits REPUBLIC OF CONGO HEALTH SECTOR SERVICES DEVELOPMENT PROJECT Difference between expected andactual Original Amount in US$Millions disbursements Project ID FY Purpose IBRD IDA SF GEF Cancel. Undisb. Orig. Frm. Rev'd PO95251 2007 CG-Agr RehabSIL (FY07) 0.00 20.00 0.00 0.00 0.00 21.37 0.52 0.00 PO84317 2005 CG-Basic EduSupt (FY05) 0.00 20.00 0.00 0.00 0.00 5.52 3.36 3.10 PO77513 2004 CG-HIV/AIDS & Health SIL (FY04) 0.00 19.00 0.00 0.00 0.00 4.74 2.28 0.00 PO81924 2003 CG-Emerg Rec & Com Supt ERL(FY03) 0.00 41.00 0.00 0.00 0.00 6.76 2.81 0.00 PO73507 2002 CG-Transp & Gov CB (FY02) 0.00 22.00 0.00 0.00 0.00 19.01 2.24 0.00 Total: 0.00 122.00 0.00 0.00 0.00 57.40 11.21 3.10 STATEMENTOF IFC's HeldandDisbursedPortfolio InMillionsofU S Dollars Committed Disbursed IFC IFC FY Approval Company Loan Equity Quasi Partic. Loan Equity Quasi Partic. Total portfolio: 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Approvals PendingCommitment FY Approval Company Loan Equity Quasi Partic. Total pendingcommitment: 0.00 0.00 0.00 0.00 128 Annex 14: Countryat a Glance REPUBLICOF CONGO HEALTHSECTOR SERVICESDEVELOPMENT PROJECT Sub- Lower- POVERTY and SOCIAL Conso, Saharan middle. Rep. Africa Income Development diamond. 2006 Population.mid-year(millions) 4.1 770 2276 GNlpercapita (Atlasmethod, US$) 842 2,037 Lifeexpectancy GNI(Atlas method, US$ billions) 648 4,635 T Average annual growth, 2000-06 Population (55 3.0 2.4 0.9 Laborforce (Yd 15 2.6 14 Most recent estlmate (latest year avallable. 2000-06) Poverty (%ofpopulalion belownationalpo veltyline) Urbanpopulation (%of totalpopulation) 61 36 47 Lifeeqectancyat birth(pars) 53 47 71 Infantmwtality(per 10Wlivebirths) 81 96 31 Childmalnutrition (%of childrenunder5) 30 D Access to imomved watersource Access to an improvedwatersourca (%ofpopulation) 58 56 81 Literacy(%ofpopulatlonage S+) 85 59 89 Gross primaryanrollment (%ofschool-agepopulation) 68 92 ID - "Congo, Rep. Male 91 98 M Lonsr-middleincomegmup ~ Female 84 86 l# KEY ECONOMIC RATIOS and LONG-TERM TRENDS 1986 1996 2005 2006 Economic ratios. GDP (US$ billions) 18 2.5 6.0 7.4 Gross capitalfonnation/GDP 29.5 27.0 22.4 23.8 Exports of goods and sewiceslGDP 39.8 68.7 86.4 910 .,T\ Trade Gross domestic savingslGDP 15.6 35.7 56.7 68.8 Gross nationalsavingsiGDP #.e -7.2 33.3 8.6 Currentaccount balancelGDP -210 -32.7 D.9 15.3 Interastpaynents1GDP 4.9 7.1 0.6 Domestic , Capital Total debt1GDP 88.6 205.4 99.4 savings formation Total debt serviceleqorls 44.9 9.3 2.3 Presentvalueof dabt/GDP 47.3 Presentvaiueof debtleqorts 54.5 Indebtedness 1986-96 1996-06 2005 2006 2006-10 (averageannualgmMh) GDP 10 3.6 7.7 6.4 - Congo,Rep GDP percapita -2.2 0.5 4.6 3.6 Lowr-middle-fnco megmup Exqortsof goods and sewices 2.7 STRUCTURE of the ECONOMY 1986 1996 2005 2006 (%of GDP) Growth o f capital and GDP (%) I Agriculture a.1 9.0 4.7 4.2 T Industry 32.6 518 69.9 73.5 Manufacturing 9.6 6.7 5.4 4.9 Services 55.3 39.2 25.4 22.3 Householdfinal consumptionexpenditure 59.4 49.7 28.0 7.4 01 02 03 04 05 W Generalgov't final consumption eqenditure 25.0 11.5 D2 D.8 -_ -GCF W G D P Imports of goods andservices 53.7 60.0 50.1 46.0 1986-96 1996-06 2005 2006 (averageannualgmMh) Growth of exports and Imports (%) Agriculture 12 2 T Industry 2.9 Manufacturing -0.2 Services -0.5 Householdfinal consumptioneqenditure -2.8 Generalgov't final consumptioneqenditure 10 01 02 03 04 05 06 Gross capitalformation 4.9 - Exports - . O - l n p O r t S Imports of goods and sewices 0.2 Note:2006data are preliminaryestimates. This tablewas producedfrom theDevelopment Economics LDB database. `Thediamonds showfourkeyindicators in thecountry(in bo1d)cornparedvithits income-groupaverage. ifdataaremissing,thediamondviil beincomplete 129 Conpo, Reu. PRICES and GOVERNMENT FINANCE - 1986 1996 2005 2006 Domestic prices Inflation (Oh) (%change) T Consumer prices 4.2 n.0 5.3 ImplicitGDP deflator -29.2 6.0 27.5 15.2 Government finance (%of GDP,includes current grants) Current revenue 34.8 27.9 39.6 46.6 Current budgetbalance 2.1 2.4 213 28.8 c Overallsurplusldeficit -8.2 43.5 6.9 8.8 TRADE 1966 1996 2005 2006 (US$ millions) Export and import levels (US9 mill ) Tota1eq)orls (fob) 673 1647 4,874 6,387 CNdeoil 471 1433 4,307 5,782 Wood 84 72 351 379 Manufactures 40 2 3 3 Total imports (cif) 627 587 I275 1533 4 000 Food 26 6 31 33 Fuelandenergy XI 215 280 293 2 000 Capital goods 203 I n 5 381 564 0 Exportprice indexpOOG=nOj 35 86 144 145 00 01 02 03 04 05 06 Import price index(200O=fJOj 69 P 1 58 56 BExports ~ l m p o r t r Terms of trade (2000=WO) 50 71 248 258 BALANCE of PAYMENTS 1986 1996 2005 2006 (US$ millions) Current account balance to GDP (Oh) Exports of goods andservices 799 1746 5.69 6.723 Importsof goods andservices 169 1,522 2,999 3,401 Resourcebalance -370 224 2,no 3,322 Net income 32 -1086 -1515 -2,731 Net currenttransfers -50 -6 -2 -1 Current account balance -389 -831 653 1130 Financingitems (net) 379 847 4 253 Changesinnet reserves XI -7 -657 -1383 Memo: Reserves inciudinggold (US8 millions) 740 1998 Conversion rate(DEC. local/US$J 346.3 5126 527.5 522.9 EXTERNAL DEBT and RESOURCE FLOWS 1986 1996 2005 2006 (US8 millions) Total debt outstanding anddisbursed 3,487 5.28 5,936 IBRD 82 82 0 0 0:280 IDA 70 I71 280 295 0: 14% C:26 Total debt service 362 339 18 IBRD 8 24 0 0 IDA 1 3 7 7 Compositionof net resourceflows Official grants 6 299 1307 Officialcreditors 90 -Q1 -n Privatecreditors 11 -14 0 Foreigndirect investment (net inflows) 22 73 724 Portfolio equity(net inflows) 0 0 World Bank program Commitments 4 0 0 2 A IBRD - Disbursements 14 4 35 8 E- Bilatrat B IDA . D. Othermltilatrd F Private - Principal repayments 3 B 5 5 C-IMF G- Si-art-teri Netflows 11 -t3 30 3 interest payments 6 9 2 2 Net transfers 5 -22 28 1 Note:This tablems producedfrom the Development Economics LDB database. 9/28/07 130 Annex 15: Packageof EssentialHealthServices(PSE) REPUBLIC OF CONGO HEALTHSECTOR SERVICESDEVELOPMENT PROJECT 1. The package o f essential health services (PSE) proposed in the Congo's PNDS seeks to support individuals and communities to participate actively in the delivery o f health services, with the support o f a competent health workforce. The list of essential health services offered in the package comprises healthpromotion, preventiveand curative services. Special emphasis will be placed on decentralized monitoring and evaluation o fthe package. The PSE would focus on: i)Healthofmothers,infants,adolescentsandtheyoung; ii)Tropicalcommunicablediseases;and iii)Non-communicablediseaseswhichincreaseCongo'sdiseaseburden. A Healthof Mothers,Infants,Adolescents andYoung adults - 2. The health status of women and children inCongo is poor as reflected inthe highrates of maternal mortality (781 per 100,000 live births), infant mortality (75 per 1,000 live births) and under-fivemortality (117per 1,000 live births). Hospital-based analysis suggests that under-five mortality i s caused mainly by malaria (3 1%), diarrheal illness (26%), acute respiratory infections (14%), and non-malarial anemia (6%). Maternal mortality is attributed mainly to direct obstetrical causes (hemorrhage (40%), abortion complications (18.8%), postpartum infections (12.7%), eclampsidHTA (1l%), dystocia (17.5%) and indirect causes (HIV/AIDS, malaria, tuberculosis, and anemia). Despite the high rates o f post natal care utilization (88%) and deliveries assisted by trained personnel (86.2%), maternal mortality remains high (DHS 2005). This paradox suggests serious problems o f the quality o f maternity care. Coverage o f emergency obstetric care (EmOC) i s poor, and access to existing services is limited by geography-related factors and high patient fees. Family planning services are almost non-existent inCongo's health facilities, and the contraceptive prevalence rate o f modem methods among women in union is 12.7% (DHS 2005). MSASF has developed a roadmap for the reduction o f maternal, infant and childhood mortality which will be implemented within the framework o f this program, focusing on: k Strengtheningsector institutionalandmanagementcapabilities 3. The institutional capabilities of the Department o f Family Health (DFH) will be updated through the reorganization and integration o f existing vertical health and nutrition programs targeting mothers, children and adolescents. Buildingthe capacity o f DFHwould entail: Reorganizing and strengthening the capacities o f DFH central and decentralized units at all levels to ensure more operational family health and social services at departmental and district levels. 131 Updating o f DSF management tools (inputs, human and financial resources, planning and supervision o f activities, etc.), taking into account the needs o f all the programs and ensuring adequacy with regard to management tools standardized by the PlanningDepartment. Posting o f qualified staff to all DFHunits (central, regional and district levels) who meet set profiles for tasks requiredat each level. Rehabilitate DFH offices (furniture, computers, supplies etc.) and supply means of transportation (vehicles and motor-cycles) for outreach and supportive supervision. Design and implement an integrated supervision program covering all activities targeting mothers, children, adolescents and youth. Instituting a decentralized performance reporting and evaluation system for annual action plans for each level. P Improvement of the provision, quality and accessibility of maternal, neonatal and infant health care, including family planning 4. The PSE for maternal and child health would focus on interventions with proven evidence o f high impact on reducing maternal and child mortality, particularly: e Improved prenatal services: settingnew norms and standards for providing at least three quality prenatal visits, improved de-worming activities, instituting improved monitoring o f at- risk pregnancies and ensuringthe referral of highrisk pregnancies to the appropriately equipped and staffed facilities for delivery. Improved prenatal services would incorporate tetanus vaccination, provision o f iron supplements, intermittent presumptive treatment o f malaria, effective distribution o f long-lasting insecticide-treated bed nets and maternal and infant nutrition education and support. e Improved delivery services assisted by trained sta8 the quality o f maternity/delivery services will be improved through proper equipping o f maternities, upgrading pre-employment and in-service training and ensuring equitable deployment o f existing experienced and qualified midwives and nurses. The coverage and quality o f emergency obstetrical surgical care (EmOC) and neonatal services will be reorganized and strengthened in each region through better communication (telephone) and transportation (ambulances etc.) to facilitate timely transfer o f pregnant women to adequately equipped and staffed facilities for complicated deliveries. 0 Carefor the newborn: training o f staff for management o f the intra-partum phase and proper neonatal care will improve survival o f newborns; the promotion o f antenatal care and maternal education on breast feeding practices will reduce infant mortality. The role o f community support will be enhanced through improved involvement in maternal health care o f better-structured health committees in promotional health and improved water supply. Postpartumcare will be strengthenedthrough joint collaboration between health committees and community delivery aides to ensure immediate postpartum referral to health centers for quality monitoring o f newborns. 0 Post-abortion care: L o w contraceptive prevalence among Congolese women o f reproductive age (15-49) results in a high number o f unwanted or accidental pregnancies, most o f which are terminated in poor sanitary conditions and result in complications leading to tubal occlusions and death; abortion-related complications i s one o f the leading causes o f death among women. Management o f such cases at all levels would be strengthened along with intensified promotion o freproductive and birth prevention education and supplies. 132 0 Maternal mortality audits: Each health facility and community will adopt a system for carrying out a maternal mortality audit. Each district and region will be responsible for collecting and analyzing these data to determine in each case the cause o f maternal death and to suggest approaches for preventing future deaths. Regional audit results to be conducted semi-annually will be discussed at the national level annually under the leadership o f the DFHand Directorate o f Social Services with support o f hospital directors and gynecologists in-charge. 0 Prevention of Mother-to-Child transmission of HIV (PMCT): All health staff attending to pregnant women will be trained in HIV counseling and testing so that these services are integrated into prenatal consultation and intra-partum care activities in at least 80% o f health centers. Pregnant women who test positive for HIV will be integrated into the regional and district HIV/AIDS treatment and follow up management arrangements for persons living with HIV/AIDS. 0 Family Planning: Access, availability and use o f family planning services will be strengthenedby integrating services in all health centers and maternity clinics and wards in the country. In addition, community-based distribution o f contraceptives will be introduced and performance family planning indicators incorporatedinhealth information systems. 0 Prevention and management of obstetric fistulas: the management o f obstetric fistulas i s still in a nascent stage in Congo, and treatment/management i s available only at the Centre Hospitalier Universitaire de Brazzaville, with technical and financial support from UNFPA. This will be expanded through the development o f a national strategic plan for eradication of obstetric fistulas. The plan will be implemented by strengthening diagnosis at integrated health centers (CSI), and improving case management at the C H U and at two other centers. 0 Prevention and management of cervical and breast cancers: Cervical and breast cancer have been identified as emerging public health problems, but Congo has no strategies for early detection and management o f the problems. MSASF proposes to develop a strategic plan, create a testing and tracking center in each district and strengthen two or three health referral facilities inthe countryto manage these cancers. 0 Prevention and management of childhood illnesses: The integrated management o f childhood illnesses (IMCI) program will be enhanced to cover growth monitoring, prevention and management o f malnourished and vitamidmineral deficiencies cases, and major childhood illnesses (malaria, acute respiratory infections, diarrheal diseases, measles, HIV/AIDS, malnutrition, anemia etc.). The package will be implemented within each community and in all health facilities to buildan effective referral/counter-referral system. A ward for oral dehydration and nutritional recuperation demonstration unit for mothers will be set up ineach health center to also serve for on-site management o f dehydration and malnutritionduring the day. 0 Control of preventable illnesses through vaccinations: Congo's EPIwill be strengthened by integrating it into routine activities of all health facilities to improve access, availability and use o f vaccination services in each district. Accordingly, each district will develop and execute district-specific improvement plans for immunization coverage, specifying the target population for each strategy and clarifying their needs in terms o f equipment (cold chain, other incidentals, etc) and vaccination materials. 0 Adolescent health services: Adolescent friendly health services will focus on the prevention o f health problems and treatment o f diseases with high incidence among adolescents and young adults, notably sexually transmitted infections (STIs), traumas, unwantedpregnancies, abortions and the abuse o f toxic substances (alcohol, tobacco and other psychotropic products). These services will be organized and delivered at the community level, inschools and at CSIs. 133 B Controlof CommunicableDiseases - 5. Communicable diseases are the main cause o f morbidity and mortality in Congo, led by malaria. Tuberculosis and HIV/AIDS are important problems as well. In addition, other communicable diseases (onchocerciasis, schistosomiasis, etc.), although occurring in limited geographic areas, cause considerable morbidity and mortality. 0 Malaria accounts for 56% o f medical consultations in public health facilities (92,406 in 2007) and has a case fatality rate o f 35.4% in hospitalized cases. Children under the age o f five years are the most affected, representing 42% of cases and 54% o f deaths due to malaria recorded by public health facilities in 2007. The Strategic Malaria Control Plan (2008-2012) adopted in2007 aims to expand access to insecticide-treated bednets to at least 80% o f pregnant women and children under 5 years o f age by 2012. It also aims to provide by 2012 rapid access to effective treatment (within 24 hours o f onset o f symptoms) to at least 60% o f persons with malaria, especially children under 5 years o f age and pregnant women. 0 Tuberculosis: Tuberculosis constitutes a major public health probleminthe Congo with a prevalence rate o f 449 per 100,000. The incidence rate i s 158 per 100,000 for smear positive TB, and 367 per 100,000 for all other forms. The case-fatality rate for TB is 112 per 100,000 (World TB Report 2005). The HIV-prevalence among TB patients is 25% (2005). A situation analysis, conducted by the National TB Control Program (PNLT) identifiedthe following major program weaknesses which will be addressed: weak managerial capacity o f the TB Program; flaws in the application o f the DOTS strategy and in quality control o f microscopy; and poor performance o f the TB Program (detection rate of TPM+: 57%; therapeutic success: 63%; defaulters rate: 29%; case fatality rate: 13%). 0 HIUAIDS: Congo's HIV prevalence rate among 15-49 old is 4.2% although there are significant regional disparities. The most-affected are people 35-39 years o f age (8.4%) and 40- 44 years of age (7.8%). HIV prevalence among women i s higher than that among men(4.7% and 3.8% respectively). Technical and financial support from IDA (US $19.0 million) enabled the Congo to launch its HIV/AIDS and Health Project (PLVSS) in 2004. Since 2006, additional financial support from the Global Fund and substantial government budget funding allowed the national program to expand HIV/AIDS/STI prevention, care and treatment to all regions o f the country. In 2007, the mid-term review o f the national program highlighted the urgency o f addressing major systemic problems within the health sector which impede successful implementationo fthe HIV/AIDS/STI program. e Other endemic and emerging communicable diseases: Diseases such as human trypanosomiasis, schistosomiasis, leprosy, Buruliulcer and onchocerciasis are endemic incertain zones and account for a few thousand consultations. District health programs in affected areas will incorporate activities to combat these diseases. Ebola hemorrhagic fever remains an ever menacing threat in West Cuvette region which has to date witnessed four successive outbreaks with highfatalities. The HSSDP will include Ebola inits disease surveillance program. 6. MSASF has adopted a holistic and comprehensive national epidemic preparedness and response strategy. Managing and coordinating the fight against communicable diseases within the Department of Disease Control and the integration of vertical programs currently being 134 implemented will benefit from more harmonized approaches. At present, ten vertical programs tackle specific diseases with limited coordination among them. The PSE will focus on : > Strengtheningof Managementcapacitiesfor the fight againstcommunicablediseases 7. The Department of Disease Control will have a division responsible for the design, supervision and management of endemic-epidemic diseases (HIV/AIDS/STI, Tuberculosis and vector-borne diseases). The Division will b e responsible for preparing and publishing activity reports on disease control and will be structured to integrate the existing vertical programs. Its management will be decentralized to regional and district levels to facilitate supervision. > Early Detectionand Managementof CommunicableDiseases 8. Case management of communicable diseases will be carried out at all levels of the health system, beginning at the community level. Access to quality care for communicable diseases will be improved through the integration of prevention, diagnosis and treatment of cases at all medical facilities, which will b e re-equipped, furnished and supplied with essential drugs, medical supplies and laboratory reagents. Technical personnel for existing health facilities will receive pre-employment and refresher course training, designed to ensure high quality essential services. 9. Community participation in combating communicable diseases will comprise the organization of activities to be carried out by community health agents, health committees, community leaders and couples. Mothers and heads o f households will be educated and sensitized on syndromic diagnosis of communicable diseases through focus group discussions where danger signs requiring referral to health facilities would also be highlighted. An essential list of drugs for household management of communicable diseases will b e defined and a package of supplies provided to communities by health facilities that serve them. C Controlof the mainnon-communicable diseases - 10. Certain non-communicable diseases, notably cardiovascular diseases and diabetes are rapidly emerging in Congo. A survey on hypertension and other risk factors for cardiovascular diseases in Brazzaville in 2004 among 2095 participants revealed a prevalence of 32.5%. The precocity of the situation is particularly worrisome (prevalence of 19% among 25-34 year olds). A study conducted in 1986 on the cord blood of newborns showed that 22.3% of subjects were heterozygote and 1.3% homozygote for sickle cell anemia. The coordination and management of non-communicable illnesses is ensured by the National Program in the fight against non- communicable Diseases, situated in the DLM. Under PSE, the program will update the institutional framework o f the management of non-communicable illnesses and strengthen managerial capacities as well as integrate early diagnosis and treatment into integrated health centers (CSIs). D PreventionandManagement ofMalnutrition - 11. Although malnutrition i s widespread among women and children (e.g. among children under five years of age, the prevalence o f chronic and acute malnutrition was 26% and 11%, respectively 135 (DHS 2005)), the Ministry o f Health still does not have a national strategy for combating malnutrition. PSE will adequately incorporate the screening and management o f malnutrition. E StandardsandConditionsof Provisionof PSE - 12. The PSE will beprovided at four levels: Community level 0 Primary health care level (health post, Army infirmary, nurse-managed dispensaries, private clinics, integrated health center, socio-medical centers, traditional practitioner centers) 0 Firstreferral level (first referral hospitals, military hospitals, clinics andpolyclinics) 0 Second referral level (regional hospitals) and Tertiary level (teaching and specialized hospitals) 13. PSE will be provided in conformity with the norms and standards that emphasize equity, effective and quality services. The norms and standards will address geographic coverage, adequate infrastructure and equipment and the distribution o f appropriately qualified staff. 136 Annex 16: Malaria in Congo REPUBLIC OF CONGO HEALTH SECTOR SERVICESDEVELOPMENTPROJECT 1. Malaria i s a major public health problem in Congo, i s endemic in all parts o f the country and transmission occurs all year roundinmost areas. The entire Congolese population is at risk, with pregnant women, young children and people living with HIV/AIDS especially vulnerable. Malaria contributes to a large proportion o f deaths and illness among children under five and pregnant women. Although most malaria episodes in Congo are not laboratory-confirmed, it i s considered a key contributing factor to the high rates o f mortality among infants and children in the country, accounting for about 71% o f deaths among children under five according to routinely reported health statistics (Direction de Lutte Contre Maladies (DLM) 2006). Congo would not attain the target for the fourth MillenniumDevelopment Goal (MDG) to reduce child mortality unless morbidity and mortality frommalaria i s reduced. 2. The burden malaria imposes on the health system i s reflected in 2005 and 2006 health statistics compiled by the DLM which indicates that suspected malaria was the most frequent reason for consultation at health facilities, accounting for 60% o f all recorded visits. Improved control o f malaria will therefore free up health sector resources (i.e. financial, personnel time and material) for other challenges facing the health system. 3. Effective preventive and curative malaria control technologies that exist today (e.g. long- lasting insecticide-treated bed nets, artemisinin-based combination therapies) are severely underutilized in Congo. Evidence from the 2005 DHS suggests that while 75% of households owned at least one bed net, only 45% owned more than one. Most importantly, only 8% o f households owned at least one insecticide-treated bed net. This constitutes a huge missed opportunity for malaria control. Congo is well-positioned to fight malaria since there i s a culture o f bednet use, especially among vulnerable groups. The 2005 DHS reports that 68% of children under five, 67% o f women o f reproductive age and 64% o f pregnant women had slept under a bed net the preceding night; however, only 6% or less of these were treated bed nets. Many other countries burdenedby malaria face a daunting challenge in getting populations at risk to adopt a newbehaviorofusinga bednet. InCongo, replacinguntreated bednets with long-lasting insecticide-treated bed nets would position the country to achieve MDGtargets for maternal and child mortality. 4. Provision o f effective treatment for malaria remains a challenge in Congo where since February 2006 artemisinin-based combination therapies (ACTs) replaced chloroquine (due to diminished efficacy) as the recommended first-line treatment. ACTs are still much more expensivethan chloroquine and are not widely available inthe country. Evenprior to the policy change, according to the 2005 DHS, among the 23% o f children under five who experienced a fever during the two weeks prior to the survey, only 22% o f them received any treatment for malaria within 24 hours o f the onset o f symptoms. Improving access to effective malaria treatment in a timely manner is critical to saving lives and will require health system strengtheningand increased involvement o fcommunities inmalariaprevention andtreatment. 137 5. In response to the high prevalence of malaria, a vertical National Malaria Control Program (PNLP) was established within the Direction o f Disease Control (DLM) alongside other vertically managed programs (tuberculosis, HIV/AIDS, onchocerciasis, schistosomiasis, etc.). Within the Roll Back Malaria framework, Congo developed and implemented a national strategic plan for 2002-2006 with the objective to reduce morbidity and mortality due to malaria, particularly among pregnant women and children under five years o f age. The program i s funded by the government and has received technical, logistic and/or financial support from UNICEF, WHO, PNUD, UNFPA, BM, the Global Fund, EU, AFD, JICA and the governments of China and the UnitedStates. Several international NGOs serve as implementing agents at the operational level; these include Doctors Without Borders (France, Holland), International Rescue Committee, Nueva Frontiera andRedCross (France). 6. A rapid evaluation of the results o f the 2002-2006 plan carried out by WHO (2007) highlightedsome progress made, includingthe distribution of treated bed nets, training o f health personnel, adopting new treatment policies with use of ACTS as first-line treatment as well as the promotion o f intermittent preventive treatment (IPT) with SP for pregnant women. The evaluation also highlightedseveral constraints, such as weak management o f the malaria control program, lack o f resources, and lack o f access to prevention and treatment services. Congo's request for Global Fund resources (Round 7 which was not approved) highlighted major challenges that impede Congo's efforts. These include poor national coverage and quality o f basic health services, inadequate resources (including a weak supply management chain for generic essential medicines), low household income and purchasing power, under-developed health information system, poor community involvement in health system management, unregulated development o f private sector health facilities and inadequate sector coordination with stakeholders and beneficiary communities. 7. The demonstrated high-level political commitment and engagement to malaria control efforts would build on existing strengths as Congo moves forward with implementation o f the PNDS. This commitment i s backed by a Government decision made in late 2007 to fund, through the budget, free malaria treatment for children under fifteen years o f age and for pregnant women. Malaria control efforts would be facilitated by the current high rate o f A N C coverage, high net ownership and improved pharmaceutical supply chain and stocks management by the COMEG (set up with EuropeanUnion support). 8. Congo's malaria control policy has been translated into a 2008-2012 strategic plan with ambitious targets (80% of pregnant women and childrensleep under insecticide-treated bed nets; 80% of pregnant women receive IPT (SP); 60% of children under five and pregnantwomen with fever access an effective anti-malarial within 24 hours o f the onset o f symptoms, etc.) which would receive additional funding from IDA. 9. Given the relative importance o f the problem o f malaria inCongo and the health sector's orientation toward achieving MDGs 4, 5 and 6, malaria control will receive requisite attention and, in accordance with the strategic plan for the sector, would be integrated with other communicable disease control programs. Specific interventions for malaria control would be integratedinto comprehensive service delivery and prevention efforts, enhancedby measures to 138 strengthen health system management and accountability, explicitly addressing human resources, procurement and supply chain management, district-level budgeting and planning and monitoring and evaluation, including sentinel site surveillance. The focus would b e on improving access to quality preventive and curative care (including integrated management of childhood illnesses (IMCI), antenatal care (ANC), community involvement and communication for behavior change, among others) beyond a single disease-specific orientation. At the same time, however, malaria control indicators will be used as "tracer" indicators to track the effect of the system strengthening measures in order to ensure that they translate to the delivery of key intended outcomes. 139 Annex 17: RoadMapfor acceleratingthe reductionof maternaland childmortality REPUBLIC OF CONGO HEALTHSECTOR SERVICESDEVELOPMENTPROJECT 1. The Republic o f Congo, with financial and technical support o f development partners, and UN agencies, adopted on December 19, 2007 a national road map (NRM)to accelerate the reduction o f prevailing unacceptably high levels o f maternal and child mortality. This initiative seeks to implement recommendations contained inregional andinternational resolutions, notably the African Union strategy and the MDGs. Congo's maternal mortality ratio (781 per 100,000 live births) is one o fthe highest in SSA. Health systemfactors that contribute to the highrates of maternal and child mortality are: 0 Disparities in geographical distribution o f basic health facilities, including basic and comprehensive EmONC facilities; 0 Generalized inefficiencies in a health system with very limited priority given to preventive and promotional health services, alongside narrowly focused, poorly organized curative care services; 0 Dysfunctional health service referral system, especially for obstetrical complications; 0 Inadequacies in technical competencies o f staff and shortage o f adequately trained staff, especially inrural areas; 0 Poorly equipped facilities, poor drug stock management (leading to frequent stock outs), and inefficient management o f other medical supplies; 0 Inefficiencies including the poor management and coordination o f maternal and child health services at.facility and national levels; 0 Weakness of community empowerment and participation due in part to insufficient behavior change communication activities; 0 Low capacity o f households for the provision o f home-based care o f child illnesses (e.g. fever, diarrhea); and 0 Deficiency o f prevention activities, especially contraception, use o f insecticide-treated bed nets and other vector control activities. 2. Other socioeconomic factors contributing to maternal and child mortality include: 0 Illiteracy associated with socio cultural barriers to appropriate promotive, preventive and health-seeking behaviors; 0 Extremely low incomes that impose financial and geographical barriers in accessing health services, particularly for EmONC; 0 Poor transport networks and under-developed communication inhibiting access to essential services; 0 Poor hygienic and sanitation conditions leading to the spread o f infections; 0 Pollutedwater supply systems contributing to the spread o f water-borne diseases; and 0 Lack o f partnerships among local stakeholders, poor inter-sector coordination and collaboration and weak linkages with communities. 140 3. Objectivesof the NRM: The NRMseeks to improve the quality o fM C H care inorder to accelerate the reduction o f maternal and child mortality and to enable Congo to achieve MDGs 4, 5 and 6. The objective o f the NRM i s to reduce the maternal mortality ratio from 781 to 390 deaths per 100,000 live births, the neonatal mortality rate from 33 to 17 deaths per 1,000 live births, and the infant mortality rate from 75 to 38 per 1,000 live birthsby 2015. 4. Achieving these targets would require: (i)improvement and strengthening o f institutional, administrative and managerial capacities o f the Family Health Directorate (FHD); (ii)improvement ofaccess, quality andavailability ofMCHcare services, including family planning, and; (iii)enhancement o f individual, family, community and civil society organizations' capacities for involvement in promotion, support and management o f the program. 5. Priority interventions in the NRM: Within the planned reforms in the MSASF, the NRMwould focus onupdatingthe legalframework for comprehensive familyhealth, including: 0 Improvement o f program budgetingandnegotiation for resources; 0 Identification, deployment and upgrading the technical skills o f staff for M C H work at all levels o fthe health system; 0 Development o f modules and clinical norms for improving the quality o f M C H care inall facilities; 0 Implementation o f the essential package o f maternal and child health in all facilities offering M C H and other family health care services; o Integration o f M C H and other family health elements within sector activities with co- management by MSASF and community health development committees; 0 Integration o f effective behavior change communication; and 0 Development o f community systems o f registration o f vital events to serve as incentives for promoting preventive health care and monitoring. 6. Implementationarrangementsof the NRM:The NRMwould be an integral part o fthe annual work program developed and implemented as health district M C H and family health operational plans under the supervision o f district health management teams, heads o f public hospitals and heads o f private health facilities. Regional directors o f health (DDS) would have the responsibility o f coordinating the preparation and review o f the regional plans within the sector-wide program, o f supervision and o f evaluation, incollaboration with health district teams and private sector health institutions in their respective regions. The DFH, within its program responsibilities, would be responsible for the conduct and technical guidance o fthe NRM. 141 Trend analysis: Reproductive Health Coverage in Congo (DHS, 2005) Maternal Mortality Ratio (WHO, UNICEF,UNFPA, World Bank estimate) Lower estimate Upper estimate Point estimate 1 ~ e Maternal Mortality in 1995, Estimates Developed by WHO, UNICEF, UNFPA 0 Maternal Mortality in 2000, Estimates Developed by WHO, UNICEF, UNFPA 0 Maternal Mortality in2005, Estimates Developed by WHO, UNICEF, UNFPA and The World Bank Number of ANC Visits (%) Congo(Brazzaville)2005: NumberofANCvisitS The latest survey shows that approximately 87% of women received ANC from a skilled provider. Ofthose w h o receivedANC services, 75% made four or more visits. NB:Gap to 100% I refers to the ANC 1 visit ANC2-3visits proportionof K 4 + visits Wm'ssirg women who did not +Kkysldlled povic'.er go to ANC. 142 Skilled Birth Attendant (%) 1.Total coverage (%) The latest survey Congo 2005 :Skilled BirthAttendant (%) indicates that more than four out o f five childbirths were assisted by a skilled birth attendant (SBA). Women residing in Total Urban Rural urban areas were reportedto have a higher SBA-assisted delivery rate than their Congo (Brazzaville) :Skilled BirthAttendant by rural counterparts by subregions (%) approximately 23 percentage points. At subregional level, the coverage varied from 73% inNorth to 98% inBrazzaville and Point Noire areas. I Brazzaville Pointe Noire Sud Nord Place of delivery 1. Total (%) Congo(Brazzaville) :Place of delivery A very high percentage (82%) o f women reported givingbirthin health facilities, with only 16% of women reporting deliveries at home. Health facility At home Other 143 C-section (%) 1 Total coverage (%) Congo (Brazzaville)2005: C-section At national level, the latest survey shows that approximately 3% o f births is deliveredby C- section. A higher proportion o f C-section deliveries was found in urban vs. rural areas (2 percentage point Total Urban Rural difference). 2. Coverage by subregion (%) At subregional level, I Brazzaville stood I Congo (Brazzaville) 2005: C-section by subregions I out with I approximately 3 to 4% higher proportion than in other areas. Between Brazzaville and the South, a 2.8-fold difference was observed. Infant Mortality Rate (per 1000 live births) 1 Infant mortality I I I Congo: Infant Mortality Rate According to the data between 1991 and 2005, both the neonatal mortality rate and the post-neonatal mortality rate seemed to have increased by 4 per 1000 birthsand 7 per 1000 1991-1995 1996-2000 2001-2005 birthsrespectively. i DHS source ~ _ _ _ _ -as- - PNN mortalit4 144 Nutrition 1. Anemia inpregnant women Congo 2005 (Brazzaviile): Anaemia in pregnancy (%I According to the latest survey, 70% o f pregnant women were reported to be anemic. Ofthose who were j anemic, the majority 3 0 4 were reportedto suffer from moderate anemia. Congo (BrazzaviiIe) - Low BirthWeight __-- _I__________- Overall, 10% of Congo (Brazzaville):Low BirthWeight II I babies were reported to weigh less than 2.5 kg at birth, with a 2 percentage point higherproportion o freported low- birth-weight babies inurban Total Urban Rural I areas compared to 2 rural areas. 145 Teenage Pregnancy 1-Total Pregnancy (%) II Congo (Brazzaville) 2005 :Teenage pregnancy Total Urban Rural I GCongo(Brazzaulle)2005 8- 2 - Teenage pregnancy by subregion (%) Congo (Brazzaville)2005 :Teenage pregnancy by subregions ' 2 ,, .,' , IO,' . . / I - Brazzavik minteMire Sud Nard At national level, the survey indicates that approximately 6% o fwomen aged 15to 19were reported to be currently pregnant with their first child. More than a 2-fold difference was observed betweenurban and rural areas. By subregional level, the proportionranged from approximately 3% inPointeNoire to 11% inNorthernarea. 146 Family Planning 1-Contraceptive Use Congo(Brazzaville) :ContraceptiveUse ( anymodernmethods) Total Rural 2 -Contraceptive by subregion (5) Congo (Brazzaville) :Contraceptive Use by subregions ( any modern methods) Brazaville Point-Noire Sud Nard At nationallevel, approximately 13% ofcurrently marriedwomen were reported to use modern contraceptive methods. Higherprevalence o f use was reported from women residing inurban areas. At subregional level, the prevalence varied from approximately 9% inNorthern area to approximately 17% inBrazzaville area. I 147 Annex 18: HumanResourceAssessment REPUBLICOF CONGO HEALTH SECTOR SERVICESDEVELOPMENT PROJECT Background 1. The health system in the Republic o f Congo has been overwhelmed by years o f conflict and inadequate financial investment. The large network o f public and private health facilities have suffered from chronic shortage o f health care workers especially in rural areas, lack o f essential drugs, supplies and equipment, shortages of water and electricity, insufficient managerial support and oversight from district and department level health authorities. Management of human resources poses especially protracted challenges for the health system. There are inadequate numbers o f health care providers in all personnel cadres (medical, paramedical and auxiliary). Even those that are available do not have the appropriate skills needed to address the population's health needs, especially in priority services, such as HIV preventionand treatment, malaria control and skilled attendance at birth.As a result o fmore than ten years o f frozen recruitment nearly half o f all health care personnel are over 40 years o f age. In addition, system for training, recruitment and deployment o f health workers i s weak. 2. The Republic o f Congo has prepared its Second National Health Plan (2007-201 1) that has as its goal the improvement o f the health o f the general population, particularly women and children by strengthening the health system. As part o f its national health and HIV/AIDS Program, the Government o f Congo has adopted a policy to cover treatment o f HIV/AIDS, tuberculosis and malaria (for mothers and children) from the central budget. As a first step towards this five-year program, the MSASF and the NAC/CNLS conducted a rapid assessment of the human resources for the health inthe Congo. OverallAssessment Objectives: 3. - The objectives o f this assessment were to: -- Rapidly assess the current status o f human resources for health Evaluate the systems that support HRHplanning, recruitment, deployment, retentionand training Develop recommendations and actions to improve the quality o f essential services and the systems that support human resources inhealth within the context o f the PNDS inCongo Methodology for HRHAssessment 4. A total o f 18 stakeholders were interviewedinthe areas o fHRHandHRIS usingan in-depth interview guide that probed issues such as availability o f policies and guidelines to provider incentives and in-service training. Sections o f the tool were applied according to the involvement and information providedby the personbeing interviewed. Interviews were conducted at the central MSASF level, the Health departmental level inPointe Noire and Kouilou, as well as partner organizations involved in humanresources for health in Congo. 5. Other evaluations related to HRHconducted before this study include: 0 Self-evaluation o f the Brazzaville medical school programs, Medical school, 2005; 0 Health service mapping (carte sanitaire), MSASF, 2005; 0 HRHstudy conductedbythe EuropeanUnion, 2006; and 0 HRHassessmentconductedbyWHO, 2006. 148 Key results andfindings 6. The findings from this study were consistently validated by stakeholders through repeated interviews and by reports preparedby the Ministryo f Health, the WHO, and the European Union. Certain common themes were visible inall studies. These include (a) the need for consistent and clear national policies and guidelines; (b) fragmented systems divided betweenministries that lack accountability for results; (c) absence o f planning and data-based decision-making; (d) little coordination between ministries and different stakeholders inHRH; and (e) insufficient capacity and capability inleadership and HR management. a) Absence o f national level policies, guides and guidelines. No national levelpolicies and guidelines exist that govern clinical or humanresource areas, such as recruitment, training, and deployment. Insome cases, there are draft clinical guidelines in selected areas such as HIV/AIDS, developed or brought inby external donors with particular interests, but none o f these guidelines have been formalized and institutionalizedinto national clinical protocols, human resources management processes, management and supervision systems or training curricula. b) HRHprocesses are fragmented and not based on assessedneeds or requirements. Fragmented and ad hoc systems govern the production, recruitment and management o fhuman resources that are divided within ministries, between ministries, and based on non-health and human resource needs. Five ministries are involved inthe management o f human resource systems: the Ministryo fPublic Administration, the Ministryo fFinance, the Ministries o fTechnicaland Professional Education, the Ministryo f HighEducation and the Ministryo f Health. Within the Ministryo fHealth, two departments managepersonnel issues: the Department o fAdministration and Personnel (DEP) i s responsible for collecting dossiers on hires, deploying them to facilities, and tracking HR information; the Department o f Studies and Planning i s responsible for training, planning and career development. Both o f these departments are severely understaffed and under qualified to perform these responsibilities. c) Lack o f coordinationbetween ministries and other stakeholders inthe areas o fhuman resource productionand management. According to most stakeholders, coordination and communication between ministries and even within ministries, does not happen very often or very effectively. Althoughthere are forums sponsored by different organizations to address these deficiencies, once the forum ended, there was little effort to continue communicating needs, gaps, and requirements. This was particularly evident between the Ministryo fHealthandh b l i c Administration, andthe Ministryo fHealthand Higher Education. An absence ofcoordinationbetweeninternational organizations and the ministrieswas also evident. On several occasions, stakeholders at boththe central level and the departmental level, regretted that international donors come in for short periods o f time to focus on one small segment or problem but do not compare notes or develop a comprehensive plan to move assistance forward consistently. The result i s that assistance is repeated insome areas (multiple workshops and seminars on the same topics with the same participants) and other areas are ignored. 149 d) Lack o f capacity and capability inleadership. HRmanapement. and supervision. Only a few people inthe MSASF are dedicated to the management and administrationo fhealth personnel and they sit indifferentdepartments. These individuals are lacking inskills and tools they need inorder to achieve their objectives. Inaddition, because many o f the HR systems are beyond their control, they can only respondto a smallpercentage o fthe needs o fpersonnel. Studies andplans have been developed by external donors as well as by the ministrybut cannot be implemented without strengthening the internalcapacity o f the ministry and the departments. Overall however, supervision practices are largely administrative and consist o f logging attendance hours in a book. Employees that arrive and depart on time are given incentives such as attendance to workshops and identifiedas local resources for visiting consultingteams that require support. Once per year, the ministryperforms audits at facilities to determine ifthey met their service goals and rates them accordingly. e) Lack o f planning and data-driven decision-making across the health sector. An overall lack ofboth informationand planningcapability was evident across all interviews. The dearth o f information i s complicated by the divided responsibilities between the ministries involved in humanresources. For example, the Ministryo f Public Administration records that i s hired, on what date, other basic demographic information, and calculates the retirement date based on the age o f the recruit. This information i s kept manually and i s not shared with the Ministry o f Health. The Ministry o f Health also collects similar information by hand and stores it inlong wooden boxes called `pirogues' inan office shared by over 15 people inpiles on the floor: one pile for `deceased or deserted', one pile for `retired' and one for `active'. There hadbeen several efforts and plans to develop an HRIS system: at the central DEP, at the departmental level inPointe Noire, and at the Ministry o f Public Administration. Inthe first two instances, the design and planning stages for an HRIS had been completed with the support o f different donors or nationalinvestment but the process had stopped there for lack o f funding. f )Almost 20 years o f a hiringand salary freeze inthe health sector have had severe conseauences in humanresources. Inadditionto anagingworkforce (according to a recent study conductedbythe WHO, over 42% o f the current health staff will be retiringwithin a decade') the lack o f activity inthe sector caused the deterioration o f other systems and processes that existed beforehand, such as planning and management practices and the advancement o f specialized fields in health care. Wages inthe public sector were frozen in 1984 and only inJanuary o f 2008 began to climb. The government has committed to paying back salaries to healthworkers at the rate o f4 months per year, but salaries remainvery low. Promotions were given to staff intitle only, and have not been accompanied by a raise insalary intwenty years. The lack o fmovement inthe sector exacerbated the talent flight to other countries and increased the opening o f private facilities with no monitoring o f quality. In addition, there i s very little transfer o f knowledge between the older generation o f health care workers and new hires, and valuable experience i s being lost. Rapport d'halvse de la Situation des RessourcesHumaines Dour la Santk: Ministhre de la Sante, WHO, 2007. 150 g) Unequaldistributionof HRHbetweenurbanand rural settings. As a result o fanunequal distribution o fhumanresources betweenurbanand ruralareas, 302 rural clinics have closed2while urban facilities have an excess number o f health workers3. Difficult working conditions inrural areas, such as lack o f infrastructure, roads, electricity, water, and housing discourage health workers from acceptingjobs inrural facilities. Inaddition, since the law requires that a married couple should live inthe same place, providers assigned to rural areas move to the cities to be with their spouses when they get married. Rural settings are also dangerous for unaccompaniedwomen. This i s a major problem inretaining health workers inrural areas as more than 61% o f health workers are women.4 The President has recently announced the re-instigation o f incentives for providers who work inadverse situations but the program i s yet to be implemented. h) InsufficientandInadequate Productiono fHumanResources 0 Pre-service Education. Some o f the deficiencies o fpre-service education include the lack o f teaching materials, such as laboratory equipment, medical supplies, computers and access to the Internet for students. Inaddition to beingpoorly equipped, the curriculum and training programi s based on the inheritedFrench system, criticized by some as highlytheoretical, and is not regularly or systematically updated or revised. Graduates are not followed up to determine where they are employed or how prepared they are for theirjobs. The medical college and the Ministryo fHealth do not communicate or coordinate on planning and management issues. 0 Paramedical Schools The paramedical schools are constrained by poor infrastructure and a sever shortage o f materials. Some colleges visited had 80 to 100 students per class and were usinganatomic models that were incomplete and inpoor condition. Inone instance, one microscope was shared between 52 students and one stethoscope for 59 students. Students at this same paramedical school inBrazzaville shared 3 computers and hadno access to the Internet; inPointe Noire, they had no computers at all. The paramedical colleges also have no communicationand coordinationwith the Ministryo f Health. Similar problems relatedto obsolete curricula and untrained teachers were encountered. 0 ContinuingEducation The Planning and Study Directoratewithin the Ministry o f Health appears to manage continuing education, but it does not have an organized unit or staff dedicated for the task. Ad-hoc training events are sometimes organized by different departments and regional directorates and by external donor organizations. There i s no nationallyaccepted curricula for essential services, although some curricula were found at the WHO office inmaternal health and HIV/AIDS; no copies o fthese curricula were found at the regional and district levels. MSP-DEP, Carte Sanitaire du Congo 2006. At CSIPoto-Poto, 75 nurses alternate days at work but are paid for full time employment. Rapport d'halvse de la Situation des RessourcesHumaines pow la SantC: Ministere de la Sante, WHO, 2007 151 Congo has no national training teams or regional and district teams trained intraining methodology; nor has it trained preceptors how to coach. Trainings that are offered are mostly theoretical and lack the practical component. Training o f health providers i s carried out inan unsystematic manner. According to some stakeholders, participationintraining events i s often politically motivated or offered as a reward with little accountability for results. Pretests have shown that the same providers have attended some workshops up to three and four times, with no improvements inknowledge. Many o f the participants are said to lack the basic training required for the training workshop. Opportunities 7. Althoughthere is little questionthat the humanresources for health inCongo is indire condition, there are positive elements that can be built uponwhile broader systemic changes take place. Decentralization i s being carried out at the departmental level and visible efforts have been undertaken to solve problems and manage change at the local level. HRdata have been presented to the central MSASF for requesting. InPointeNoire the team saw hand-written charts on the walls o f the departmental office that listed facilities, numbers o f clients, and other healthrelated statistics for tracking purposes. The Ministry o f Health, as part o fthe Project Sectoriel deDiveloppement des Services de Santi,with the support o fWHO and the World Bank, have developed anHRHAction Planas an outcome o fa workshop held inBrazzaville inDecember o f 2007. The plan includes specific steps and requirements for meeting both short and long term goals. The President has recently announced steps that will help improve salaries and incentives for public sector workers. These programs have not yet been implemented, and additional support may be needed from internationaldonor organizations to move this program forward. Conclusionsand Recommendations 8. Congo's human resources are imbalanced, inadequate and under-qualified. Outdated and problematic laws create difficulties in training, recruitment, deployment, and public sector employment. Corruption i s commonplace. Infrastructure, materials drugs and medical supplies are inadequate. Moreover, the internal capacity at the Ministry o f Health is inadequate and lacks the capacity to address these problems. 9. Addressing each o f these weaknesses in a piecemeal fashion will be at best, only marginally effective. Before real change can take place in facilities and in the field, change needs to occur at the organizational and structural level. Long-term and consistent external technical assistance and support from a consortium o f donors will be required for policy development, strategic planning, process design and improvement, human resources management, clinical guidelines development, HRIS, incentives systems design, supervision systems design, and quality control and monitoring. a) Identifk and develop key leadership responsible for initiating and implementing maior changes inthe public sector. Leaders within all involved ministries should be identified and should form an intra-ministerialleadership group for creating a collaborative environment necessary inthe public sector, and reports to the President. Inaddition, this leadership group must discuss and act on changes inpolicies and laws that must be implementedinorder for sectoral improvements to occur. This umbrella organization should be supported by external aid organizations such as the World Bank, WHO, 152 UNICEF and the European Unionwith technical expertise, leadership development, and the creation o f an organizational framework, charter, and working set o f bylaws. b) Organize and maximize external aidand donor support. The agenda for this leadership group should include the organization and direction o f external aid and donor collaboration to ensure that it effectively advances Congo's strategic agenda ineach sector. The representative o f each sector should produce a portfolio o f aid projects and recommended investments that target advancements or weaknesses inthe sector. All donor organizations should be requiredto interface with this group and submit proposals for assistance to ensure that projects compliment each other and meet the broad needs o f the health sector. c) Reorganize the Ministryo f Health to manage HRprocesses to foster collaborationand communicationbetween departments. This redesign should come as a result o f strategic planning and HR system and process design exercise that i s facilitated by an external organization and validated by internal stakeholders. The new design should include a designated departmentfor the management of human resources. This HR department should participate and or lead the change management o f the health sector, should be responsible for managingHRprocesses, and be heldaccountable for the outcomes. d) Buildorganizational capacity inleadership, management, HRmanagement. and systems design. The capacity o f individuals responsible for HRmust be developed and strengthened. Long-term and repeated leadership and management training should become a pillar o f the development agenda offered by any internal or external organization. An extreme culture o f corruption currently exists within the public sector in Congo (most probably inthe private sector) and concerted efforts are needed to change that culture. e) Develop and disseminate national clinical and HRpolicies, guides and guidelines. An integrated working committee should be formed that represents key players inhealth, includingrelevant ministries and internationalorganizations. The working committee should be responsible for the development o f national policies and guidelines for clinical areas as well as HRHareas and should include participants knowledgeable inpolicy designand implementation, clinical guidelines for the essential services package, and humanresource systems. These policies and guidelines should be based on international standards but tailored to the Congolese context. I t i s highly recommended that this committee be supported by technical assistance from appropriate donors, should sit within the Ministry o f Health, and shouldmeet on a regular basis to update and revise guidelines. 0 Clinical guidelines shouldbecome the basis for protocols, training curricula, job descriptions, andjob aides, and recruitment criteria. Inaddition, these guidelines should become the foundation for the develop qualifications and standards for pre- service and in-service education. 0 Human resources guidelines should be developed to govern the processes o f recruitment, deployment, incentive structures, career development, and supervision. f ) Develop and implement an HRIS that meets the needs o f the health sector. Strengthen or builduponexisting systems for tracking employees, monitoringperformance, providing data for planning and analysis, and projecting hture human resource needs. Evaluate the proposed system sponsored by the Ministry o f Public Administration and ensure that it 153 meets the needs o fthe health sector. Alternatively, request changes to modify the proposed system or, develop a compatible (not duplicative) system that provides and tracks information requiredby the health sector. Establish quality control systems. quality improvement processes, and monitor the results. NB: More information would be inthe final report Develop fair and equitable incentive systems for health workers. Implement the incentive scheme announced by the President. Under the scheme incentives will be offered to healthcare providers who perform duties under adverse conditions, such as in rural environments, as `on-call' providers, inrisky situations, etc. Additional incentive schemes should be developed that supplement the salaries o f workers inrural environments. Other incentives could be offered by: Involvingthe community ina cost-sharing partnership with the health center whereby the community contributes to the salaries and income o f the health worker, provides room and board, etc.; Recruiting health workers from rural environments, with community involvement and offering them scholarships ifthey return to their villages to practice Accelerate the pace at which base salaries reach an acceptable level and individuals who have received promotions inthe past two decades receive the appropriate salary increases. Base salaries o f health workers must be equivalent to private sector salaries. It i s known that public sector providers work inthe private sector for additional income. To paraphrase one high-level stakeholder, `we close our eyes to it - ifwe stopped providers from working inthe private sector, we'd have none at all inthe public sector.' Continue and expand the current cost-recovery strategy inwhich 20% o f the cost o f a health visit or intervention i s paid to the health care provider. Invest in infrastructure, suoulies, and drugs. NB: More information would be inthe final report Emphasize coordination, planning and needs-based program design inall aspects o f Trainin% a. Pre-service education: i. MedicalSchool e Create an institutionalcoordinationcommittee between the MSASF, the Ministry o f HigherEducation and the Medical School responsible for the periodic review update o f educational programs. e Conduct a needs assessment o f supplies and equipment for the Medical School and stock neededmaterials. e Conduct a needs assessment to determine desired outcomes for program redesign by interviewing and involvinggraduated students, health care providers, patients, etc. e Base curricula standards on national policies and guidelines and develop didactic materials that reinforce new protocols. e Provide faculty with a knowledge and teaching skills update. e Develop relationships and partnerships with other medical schools 154 ii. Paramedicalschools 0 Create a coordination committee betweenthe MSASF and the Ministryof Professional Education 0 Needs assessment o f missingtraining materials 0 Needs assessment of community needs, provider needs and schools' needs to guide reviewand redesignofparamedical training programs 0 Positionthe paramedical schools under the MSASF control 0 Update teachers intraining methodology and preceptors incoaching skills 0 Create an accreditation system b. Continuing education: Continuing education should be under control of the new department of human resources inthe Ministry ofHealth. Partofthat responsibilitywill beto reviewandupdatetraining programs, track training information, develop curricula for continuing education, recruit and train trainers and preceptors, and ensure decentralization of training programs. 155 Annex 19: Empoweringcommunitiesin Congo's healthservices deliverysystem REPUBLICOF CONGO HEALTHSECTOR SERVICESDEVELOPMENT PROJECT A Background - 1. Enhanced role for beneficiary communities: Improvement in the health status o f Congolese requires the full engagement of beneficiary communities for identifying solutions to the prevailing high burden of disease and excessive mortality. Community participation has remained a challenge in spite o f the establishment of community participation organs (COSA/COGES/CODIR). Empowering communities as co-managers o f health services with special focus on the package o f essential health services defined in this sector program will require overhauling existing statutes and institutional and strategic arrangements which would create a two way process from MSASF and community perspectives. It will entail building o f capacities within the MSASF's central and decentralized units to coordinate government- community partnerships and strengthen community participation in the management o f heath delivery services. 2. A leaal basis for such community partnership inhealth exists inCongo's commitment to health as expressed in Article 7 o f the Constitution (2001) which recognizes that every human being is sacred and has the right to life which the State is obliged to respect andprotect. Several articles o f the Constitution recognize the State as the guarantor of public health; offers options for private persons to establish and run private health facilities; obliges the State to assist families; requires families to carefor all children in the household; gives Parliament the right to fund health services, and; establishes a Conseil Economique et Social with the right to review and to act on economic and social issues includingfunding of social sewices (see Articles 7, 30, 31, 32, 111 and 157). Congo's Decentralization Law (Loi No. 7-2003 du 6fevrier 2003) grants 32 districts (communes) powers to construct, equip, maintain, manage and ensure the maintenance of all facilities and equipment in health posts, health centers, integrated health centers and social service centers. Communes are responsible for ensuring environmental hygiene, managing social assistance sewices provided to vulnerable persons as well as for planning and carrying out emergency plans for national or man-made disasters. Communes are required by the law to keep premises of health centers clean at all times (with exception of hospitals which are cleaned by paid employees). The law (Loi No. 3-2003 de 17fevrier 2003) defines the structures for decentralized administration from central government organizations through regional councils down to the village level. However, these laws contain neither specific reference to development committees nor mention o f health committees (COSA, COGES, CODIR). 3. Community participation in health care in Congo i s sanctioned in Decree No. 96-525 o f 31 December 1996 which created elected health committees comites de sante (COSA), for integrated health centers (CSI); the comites de gestion (COGES) for first referral hospitals management committees and the comites de directions (CODIR) for regional hospitals. These committees are responsible for organizing and sustaining dialogue between beneficiary 156 communities and health facilities including hospitals. The 1996 Decree provides for COGES to participate inthe preparation o f hospital action plans, monitor and co-manage hospital resources, approve facility budgets, accounts and activity reports and helpresolve institutional, security and environmental hygieneproblems. Eachparticipatory organ is also charged with providing regular health informationto the population. However no appropriate legal and statutory framework i s in place for effective operation o f these committees and their roles and internal regulations remain ill-defined. Financial management mechanisms for these bodies have not been specified. Furthermore, unequal access to services, especially for most vulnerable groups, reinforces the alienation o f communities from health services designed to resolve their problems. Indeed, the PNDS regrets that no first level referral hospital has a functioning COGES and that most COSA are moribund and few regionalhospital management boards (CODIR) ever holdregular meetings 4. At the present, community-based committees are basically donor-created organs lacking legal and operational linkages to the government's decentralized structures (Conseils departmentam, conseils municipaux et communaux). There are currently specific ways o f ensuring transparency in CODLR elections or inthe designation o f community representation in these hospital committees. A new legal framework for community outreach and participation in development in general and in health services, inparticular, will require detailed analysis o f the existing committees. New statutes will have to be developed for improving group dynamics and partnerships for effective community participation inhealth services management B Congo's experience with communityparticipationinhealth - 5. A critical review o f Congo's experience with community participation inhealth services outreach and co-management reveals a sketchy uncoordinated adoption o f the Bamako Initiative of I987 and the District Health concept. The two initiatives emphasized decentralized management o f services, enhanced community involvement in health response, co-management o f essential drugdcost recovery (sharing) and mobilization of additional local resources. Many COSAs were set up to rationalize CSI activities and to ensure successful delivery o f basic health services. Despite weaknesses such as under representation o f women, poor training, low participation in health activities, low involvement in health planning, and program implementation, it is still recognized that the COSA, COGES and CODIR are crucial for success inhealth care. These organs were set up without thorough analysis of membershipcomposition and o f roles they should play. None o f them had proper legal mandates within which to function. Despite decentralization, regional development councils (Conseils de developpement) remain poorly organized and do not provide effective support to COSA, COGES and CODIR. Inadequate organization and poor management capacity have limited the roles and effectiveness o fthese organs. C Proposed communityparticipation - 6. Proposed community participation under the PSDSS is based on two strategic choices focusing on: 0 The promotion of stronger engagement and participationo fcommunities inimproved quality health services; 157 0 Promotion o f equitable and more sustainable access to available health services for vulnerable population groups. 7. Activities are planned to strengthen the engagement and participation o f communities in health services through 10 tasks covering the revision and adoption o f new texts defining the functions and roles o f COSA, COGES and CODIR, training for regional and district health teams for settingup and carrying out supportive supervision o f to the committees to strengthenthe co- management o f health programs. Activities under the PSDSS would include 18 distinct tasks to raise the level o f knowledge, the attitudes and practices o f communities on health matters (malaria, nutrition, HIV/AIDS,TB, IST, vector control, leprosy and other emerging diseases. A set o f 10 tasks have been retained for strengthening home-based care and treatment, for designing modules and guidelines for training CHWs, , on major communicable and vector- borne diseases, management o f community kits for essential medicines for home-base treatment and care, maternal and child health, community health awareness activities, use o f essential medicines and commodities, promotion o f nutrition and exclusive breastfeeding; prevention and treatment o f HIV/AIDS, STIs, TB, onchocerciasis and intestinal worms . A regional community health coordination service will be created within each regional directorate o f MSASF. The regional coordination service will be responsible for coordinating community health activities with a special focus on the selected package o f essential health services (PSE). Collective actions by each community (quartier and village) working jointly with assigned MSASF health and social affaires personnel will require appropriate legal mandates (integrated within the overall conseils de developpement)with clear guidelines for required linkages to other local governance initiatives. 8. Equity and sustained access to health services for vulnerable population groups: Activities retained to promote equitable access to health services by the poorest and most vulnerable groups, including pygmies, would involve identifying and testing solidarity mechanisms for local health insurance initiatives. Since pygmy groups tend to be mobile, the PSDSS would establish and manage mobile clinics jointly with pygmy CHW and NGO/CBOs (drawing from the initiative in of the Betou clinic in the Sangha Region) in the regions o f Lekoumou, Sangha Plateaux and Likouala. 9. Proposed steps for developing communitv Dartkipation inPSDSS: The primary goal i s to ensure that the voice o f consumers i s enhanced through community participation. An inventory and analysis o f legal documents will be carried out to facilitate these reforms. The analytical work will include: 0 Documenting - best practices from ongoing community initiatives 0 Reviewing current constraints to collective participation indevelopment activities and suggesting appropriate solutions and new legal and administrative arrangements for invigorating community participation inhealth. 0 Proposing a plan o f action for creating and sustaining viable health committees to improve the co-management o f the delivery o f PSE 0 Drafting, approving and promulgating new texts that grant COSA, COGES and CODIR recognized roles and legal rightsas co-managers o f Congo's health care services. 158 Preparing guidelines and modules for reorganizing, restructuringand training new memberso fCOSAs/COGES/CODIR inco-management o fhealthservices. D Focus on vulnerable and indigenousgroups - 10. Special attention to most vulnerable groups: The PNDS recognizes that vulnerable groups, particularly the very poor and indigenous such as pygmies have limited access to health services. To reduce these inequalities in health care access, the government has allocated state funds for training community health workers, to be drawn from members o f these groups, for prevention and treatment o f malaria, HIV/AIDS, tuberculosis, onchocerciasis, leprosy, cholera, traumas and emergency needs o f pregnant women and children. Participatory dialogue has been carried out with pygmies and with other vulnerable groups. Such empowerment i s necessary to encourage community involvement in health care provision. Specific indicators have been developed to track the level o f community participation and its impact on access and quality of care especially among vulnerable groups. 159 3 za s .3 Y a Y a2 B c .-.I 5 a E Y L 0 a a a E v) L % 0 v) 2L X X X .-$2 cp X X X X L 0 .-.I cll .. 0 s c.l 3 X X X X X X X I x X X X X X X X X Y g P -Q L b .e 0 m 0 2 2m 48 -8 a * .e 0 .c ?, a M .e I e, 2 & h I e h .-.**e, v1 .e d? 0 s ri 3 - !i l - X x II xx X IIbxx X I X X I X X I X X I X . aea .-k .I 0 L 0 - - - - X X X X X X X X - - X X x X X X X X X X X X N -B -.I e, * m :: 3 d X X X X X X X I X X x X X X X X X X X X X X X X X X X X X X X X X X X X c) .eC L E .-0E . m v1 pt 0 .I L k 0 .I Y P:: 28 aI v1 a PL X \o \o 3 X X .-.-P L . I Y f a .-'5k 0 3 vl I se .. ye, 0 38 sI Cn 3 Annex 21: NationalHealthPolicyLetter REPUBLICOF CONGO HEALTH SECTOR SERVICES DEVELOPMENT PROJECT A I 167 I. 1 1 ... 111. i b . v. \ i. vii. 168 169 Annex 22: Map REPUBLICOF CONGO HEALTH SECTOR SERVICES DEVELOPMENT PROJECT 170 10° 20° N I G E R I A CENTRAL AFRICAN REP. Niger C O N G O CAMEROON Gulf of Guinea EQ. GUINEA SÃO TOMÉ & PRIMARY PAVED ROADS INTERNATIONAL AIRPORTS 0° PRINCIPE CONGO 0° GABON PRIMARY GRAVEL AND EARTH ROADS OTHER AIRPORTS Congo SECONDARY ROADS PORTS DEM. REP. OF CONGO TRACKS RIVERS Brazzaville CABINDA RAILROADS MARSH (ANGOLA) REGION CAPITALS REGION BOUNDARIES A t l a n t i c OTHER SELECTED TOWNS INTERNATIONAL BOUNDARIES O c e a n 10° 10° A N G O L A 10° 20° ZAMBIA 12° 14° 16° 18° CENTRAL AFRICAN REPUBLIC Lobaye Songha C A M E R O O N Bétou Boumba Dja Motaba Oubangui Bomassa Boucy-Boucy Ntam Souanké Bolozo 2° Dongou 2° Ngoko L I K O U A L A Sembé Mohitou Giri TORIAL Mokéko Ouesso Impfondo S A N G H A Ketta GUINEA Epéna EQUA Congo Liouesso Mambili Lengoué Likouala Pikounda Mbomo Sangha aux Yengo Herbes Etoumbi Likouala Ekouamou Mbandaka 0° G A B O N Likouala Kéllé Makoua 0° R É G I O N D E L A C U V E T T E Owando Kouyou To Akiéni Ewo Obouya Loukoléla Boundji Oyo Alima Mossaka Alembé Ollombo Tchikapika Abala Okoyo To Franceville DEMOCRATIC To Moanda R É G I O N Nkéni Gamboma 2° D E S REPUBLIC OF 2° Mbinda P L A T E A U X Mayoko Lékana Okiéné CONGO Bambama Ogoué Nyanga Ngo Djambala Mpouya Divénié Nyanga Etsouali Mossendjo Zanaga Mpé Léfini N I A R I L É K O U M O U Inoni Kasai Komono Ngabé Vinza Kibangou Makabana Niari Bouenza Loukouo Sibiti Odziba P O O L Congo Bihoua Kindamba Niari Mayama Nzambi Mouyondzi 4° Nkola Kakamoéka 4° Loudima Madingou P.K.Rouge Loubomo Niari K O U I L O U Mont Mindouli Nkayi Mvouti Belo Brazzaville KouilouMalélé B O UBoko-N Z A E Kinkala Linzolo Kinshasa 0 50 100 150 200 250 Madingo-Kayes Makola Kimongo Songho Guena KILOMETERS Hinda Boko Pointe This map was produced by the Map Design Unit of The World Bank. Noire Londéla-Kayes The boundaries, colors, denominations and any other information shown on this map do not imply, on the part of The World Bank Group, any ATLANTIC judgment on the legal status of any territory, or any endorsement or IBRD JUNE CABINDA Congo acceptance of such boundaries. (ANGOLA) 28865 1997 OCEAN 12° 14° 16° 18°