Page 1 PROJECT INFORMATION DOCUMENT (PID) APPRAISAL STAGE Report No.: AB1417 Project Name DRC Health Rehabilitation Project Region AFRICA Sector Health (100%) Project ID P088751 Borrower(s) DEMOCRATIC REPUBLIC OF CONGO Implementing Agency Health Ministry Dr Miaka Mia Bilenge Constantin Boulevard du 30 juin n Congo, Democratic Republic of Tel: 243 99 042 94/081 81 49 261 bctrdc@ic.cd Environment Category [ ] A [X] B [ ] C [ ] FI [ ] TBD (to be determined) Date PID Prepared February 23, 2005 Date of Appraisal Authorization March 14, 2005 Date of Board Approval May 27, 2005 1. Country and Sector Background Potentially one of Africa’s richest economies, the Democratic Republic of Congo (DRC) is one of the poorest countries in the world . It is emerging from a decade of civil war and thirty years of mismanagement. Per capita income declined steadily from US$380 in 1985 to US$85 in 2000 and is estimated at US$100 in 2003. A solid and ambitious economic program, supported by the Bretton Woods Institutions, has been implemented satisfactorily since April 2001. A transition government encompassing most parties in the civil war has been fully in place since September 2003 which puts an end to the violent division of the country and creates a political environment conducive to economic and social reunification, although insecurity continues in parts of the East of the country. Social indicators, already low before the war, have dropped further in recent years and the chances for DRC to achieve the Millennium Development Goals (MDGs) by 2015 are seriously compromised . The population of DRC is large, growing fast, and very young. With an estimated 58.3 million people in 2004, the population of DRC is the third largest in Sub-Saharan Africa (after Nigeria and Ethiopia). Estimated annual population growth is 2.9%. (US Census Bureau, 2004) With its high fertility and mortality, almost half the population (48%) is under 15 years old and only 3.5% is over 60. The majority of the Congolese lives on the equivalent of US$0.20 per person per day, and consumes less than two thirds of the daily calories needed to maintain good health. The collapse of the education system and the increasing rate of illiteracy are alarming. Page 2 Overall mortality - An estimated 3.8 million “excess” deaths have been associated with the conflict in DRC since 1998 . The increased mortality associated with the conflict was not due to direct violence, but to deterioration of socio-economic, nutrition, and health conditions. Data on the causes associated with reported deaths from 2004 retrospective mortality surveys show that most mortality is due to increased malnutrition and disease caused by displacement and socio- economic disruption due to the conflict. (IRC, 2004) Many health-related MDG indicators are worse than Sub-Saharan Africa averages, with levels of child and maternal mortality among the highest in the world. 1 (i) Child Health · At least one in five DRC children dies before the age of five years and one in ten infants die before their first birthday. DRC has the fifth highest number of child deaths of any country in the world (565,000 per year) and the ninth highest under-five mortality rate (220 per 1,000 live births). Child mortality has risen dramatically in the past decade. It is higher and has increased faster in rural areas; increased mortality is concentrated in conflict-affected regions, but is evident everywhere in the country. Extremely high rates of child mortality have been experienced by many conflict-affected and other populations. For example, from a retrospective mortality survey in 2002, the implied under-five mortality rate of 432 per 1,000 in Basankhusu (Equateur) is exceptionally high. It means that if the observed crude death rates during 2002 prevailed during the first five years of a birth cohort, 40% of those children would die before reaching their fifth birthday. There are large and increasing disparities in the child mortality experiences of the poorest and the most well-off. However, while the most well-off experience less child mortality, there is little difference over the rest of the socio- economic scale, suggesting a situation of mass poverty and widespread vulnerability. Models assessing change over time in the effects of important determinants of child mortality 2 show that while high child mortality continue to be experienced by most of the population – urban and rural, poor and better-off, it seems that the access to health services may have a significant protective effect. · Malaria, diarrhea, respiratory infections, malnutrition, and measles are the main causes of child mortality. The pattern of child morbidity is similar to other poor countries in SSA. Although fever could accompany different types of infection, the fact that surveys have found that it is associated with 40% of child deaths testifies to the heavy burden of malaria in the country. The low vaccination rate and deterioration of preventive health efforts have led to occasional outbreaks of Tuberculosis, Diphtheria, Tetanus, Polio, and Whooping Cough. · The prevalence of child malnutrition, particularly wasting, is high. Chronic malnutrition (stunting) affects 38% of under-five children, which is comparable to the estimated average for SSA. However, acute malnutrition (wasting) reflective of shortfalls in nutritional intake in 1 Situation analysis is based on the DRC Country Status Report – Health to be finalized in March 2005, and data from the 2001 UNICEF Mulitiple Indicator Cluster Survey (MICS2). 2 used in preparing the DRC Country Status Report for Health (CSR-H) Page 3 the immediate, is at 16%, higher than the average of 10% seen in other countries of SSA, reflecting economic and social crisis. (ii) Reproductive and Maternal Health · The Maternal mortality ratio is one of the highest in the world (1,289 deaths per 100,000 live births or about 36,000 maternal deaths annually). The target for the fifth MDG for DRC is a ratio of around 320 per 100,000 live births by 2015. This is certainly unattainable, although significant progress is possible with sufficient effort and investment. · The total fertility rate of 7.1 is one of the highest in Africa, and is not decreasing . This is consistent with the level of poverty, lack of access to family planning, and high child mortality. Modern contraceptive use is 4%, among the lowest in the world. · Adolescent fertility is particularly high . The 2001 MICS2 found that 20% of girls aged 15-19 were mothers. Adolescent motherhood is more common among the poorest (26% in the lowest quintile, compared to 13% in the highest). · Mothers die in childbirth due to lack of access to emergency obstetric care, delays in seeking and obtaining such care, and often poor quality . For example, a study of two rural referral hospitals in Nord-Kivu in 1995-96 found that women who lived 90 minutes walk or more from the hospital had greater risks of obstetric complications. In addition, unsafe abortion is an important cause of maternal death. · Poor maternal health and care lead to poor pregnancy outcomes . A sixth of mothers are malnourished . The 2001 MICS2 measured the body-mass index of non-pregnant mothers, estimating that 17.3% are malnourished. Neonatal mortality (under one month of age) in DRC is not known. In other countries of Sub-Saharan Africa it can account for half or more of infant mortality (under one year of age), which is estimated at a very high 128 per 1,000 in DRC. · Many girls and women (and some boys and men) are victims of sexual violence associated with the conflict, particularly in Eastern DRC. Thousands of women and girls, particularly in Eastern DRC, were victims of sexual violence committed by members of the different armed groups involved in the conflict. Medical consequences include HIV/AIDS transmission and reproductive health problems, particularly fistulae. There are also serious psychological and social effects, particularly ostracism by women’s family and community. (iii) HIV/AIDS, malaria, and other diseases · Adult prevalence of HIV is estimated at 4-5%, which indicates an epidemic which has spread from high-risk groups to the general population . The economic disruption and isolation due to the war may have kept the epidemic from increasing at a faster rate in recent years, although large groups, such as displaced persons, have likely become more vulnerable to the disease. It is estimated that about 1.1 million people are living with the disease, among whom almost 60% are women, and that 100,000 deaths annually are caused by AIDS. An estimated 770,000 children are orphans because of the disease. · All of the population of DRC is vulnerable to malaria, which is the single most important cause of morbidity in the country . It is estimated that 97% of the population is at risk of endemic malaria, while the remaining 3% are vulnerable to epidemic malaria. It is estimated that children under-five suffer between 6-10 fevers episodes of malaria per year– Page 4 for an implied total of 80-100 million (!) cases. Not surprisingly, malaria is estimated to account for at least one third of outpatient consultations at health facilities. · Malaria is the number one killer of under-five children in DRC and a significant cause of mortality among older children and adults . Recent retrospective mortality surveys show that fever is associated with 40% of deaths of under-five children in both the western and eastern halves of the country. Assuming that 80% of these fevers are due to malaria implies over 180,000 annual deaths of under-five children caused by the disease. The data also indicate that fever is also the most common reported cause of death for older children and adults – around 20%. (IRC, 2004). Malaria is an important contributor to poor maternal health, directly and indirectly contributing to maternal mortality. · Drug resistance to existing malaria treatments have emerged as a serious problem in some parts of DRC . The official treatment policy for malaria is sulphadoxine- pyrimethamine (SP). Chloroquine, however, is still widely used despite significant drug resistance. Resistance to SP has also developed in parts of DRC, primarily in the east. Efficacy trials are currently being conducted to test different first line treatment alternatives; artesminin-based combination therapies (ACTs) will likely be required, and with them increased costs (approximately 10-15 times the cost of SP). If Artemether-Lumefantrine (Coartem Ò ) is chosen as the new first-line treatment, implementation will need to be reconciled with projected shortfalls of drug availability on the international market as well as the fiscal pressures on the sector. Finally, intermittent-presumptive treatment (IPT) of malaria in pregnant women will be expanded to prevent malaria in pregnancy. · Tuberculosis (TB) incidence is high, seems to be increasing, causes a significant proportion of mortality, and is associated with HIV infection . The National Tuberculosis Program estimates annual TB incidence at 384 per 100,000 population. Incidence may be increasing, as the number of notified cases has increased steadily since the early 1990s. It is thought that 25-30% of TB cases are also infected with HIV. (WHO, 2004) Social stigma adds to the burden of those suffering from the disease and hampers control efforts. · A number of other infectious diseases are endemic in some populations or erupt in periodic epidemics . These include meningitis, trypanosomiasis, onchocerciasis, leprosy, schistosomiasis, plague, ebola virus, and others. The public health system has largely collapsed . In 2002, the health sector’s budget was about 1% of the total budget. By 2004, it had increased to about 7% and serves mostly to make irregular and very low salary payments to government health workers. As a result, many health workers lack motivation and perform poorly. An estimated 70% of the population has little or no access to health care. Hospitals and clinics, particularly in rural areas, have been devastated. A large proportion of the population, particularly in rural areas, does not live within reach of health services. In one location in Equateur province, for example, a survey in 2004 found that 42.7% of households need to walk over eight hours to reach a health facility. Similarly, higher-skilled health personnel are lacking in numbers and quality, particularly in rural areas. In 2003, there were around 1,500 doctors reported to be working in the country, for a ratio of physicians per 100,000 population of around 2.6, among the lowest in the world. Nurses are in comparatively greater supply, as there were 27,000 in 1998, for a ratio of around 50 per 100,000 population, although the numbers working have declined since then. Drug supply is fragmented and inefficient although there are recent efforts to rationalize the sector through the development of Page 5 regional distribution centers. Outreach and community-based services are weak, benefiting only those persons who live in close proximity to health centers. Even when services are available, they are poorly utilized . Lack of Government funding and cuts in external assistance during the 1990s meant that households were left to shoulder the bulk of the cost of health services, including much of the remuneration for health staff. Widespread poverty and relatively high users’ fees depress utilization of health facilities. Some NGOs have documented reductions in utilization as high as 40% associated with increases in user fees; conversely, increases in utilization have been observed with reductions in fees with the start of external assistance. There is little question that, in the pursuit of health, a significant number of families are being thrown from a marginally acceptable level of income to below the poverty line – a condition that could be referred to as iatrogenic poverty. In addition to cost, deficiencies in service quality, particularly drug availability, has severely affected utilization, as well as the perception of the health system by the Congolese population. Weak capacity of the MOH to carry out the stewardship and oversight function. The GDRC is currently focused on increasing coverage of basic health services throughout the country. Where services are available, there is weak capacity at all levels of the health pyramid, to oversee their quality, particularly in the private sector, and to effectively plan, budget and manage the limited resources available. In addition, Government has not paid enough attention to its important role in the areas of strategic and financial planning. Sparse or no information exists on the effects of Government policies on out-of-pocket health expenditures by vulnerable groups. Government’s policies in the pharmaceutical sector need strengthening. Yet, there are opportunities for positive change . · The Health Zone model for integration of primary and first-referral services was pioneered by the country in the 1980s and remains the basis of the system. This structure, as well as Government’s strong commitment to it, provides an excellent basis for further development of the system. · There is a strong public-private partnership in health system development, with NGO-run facilities to a large extent integrated in the zonal health system. DRC Government has successfully introduced partnership agreements with a few international NGOs for the provision of essential services in underserved areas. · There is increasingly a culture of results-focus and the MOH is encouraging the move from process-based to performance-based partnership agreements (PPAs) between NGOs and health facilities as well as Health Zone management teams. So far, this approach seems quite promising. 2. Objectives The Project Development Objective is to significantly improve the availability and utilization of quality essential health services for the population of targeted geographical areas, particularly women and children. This will be achieved by strengthening the existing public health system at Page 6 all levels, with special attention paid to the district level and the health zone. Improving geographical access, reducing financial barriers to utilization, improving the quality and effectiveness of care, and strengthening the capacities of the front-line service delivery system, are priorities for the project. The project Key performance indicators (KPIs) will be in line with the MDGs. 3. Rationale for Bank Involvement Positive client initiatives in sector : Overall, Government strategy and policy are appropriate to the health situation and provide a good foundation for reconstruction and development of the system . Analysis of the health situation makes clear that the DRC population suffers from an enormous burden of morbidity and mortality from causes which can be prevented and treated at the primary and first-referral levels. The focus of the Government and external donors on basic health services is therefore entirely appropriate. The Government’s emphasis on decentralized service delivery through the Health Zones and its embrace of partnerships with church groups and NGOs are important advantages for reconstruction and development. Functions of the different structures of the Health Zone are well-defined, and essential packages of primary and first-referral services reflect the epidemiological situation and follow international best practice. The health information system has also been well-designed, focusing on a limited set of basic data, although there are significant gaps in implementation. The current focus of the bulk of external assistance on direct support to the recurrent costs of basic health services is what is required to have an impact on the extremely poor health situation of the population. The MOH is keen on strengthening its stewardship role, while devolving responsibility for the supervision and management of health activities to the provincial and district levels. It is also serious in promoting greater cohesion in the sector and tries to ensure a targeted and equitable delivery of health services throughout the country. Request for IDA Assistance : The GDRC organized a Round Table meeting for health in Kinshasa (May 11-12, 2004) during which all partners reaffirmed their commitment to support the sector. Donor coordination is being strengthened through continuous dialogue with major partners including bilateral organizations, particularly the Belgian Cooperation, USAID, multilateral agencies especially the European Union, the African Development Bank, UN agencies, and a broad variety of NGOs working in the sector. In November 2004, the GDRC sought assistance from its development partners for its Minimum Partnership Program for Transition and Recovery ( Programme minimum pour la transition et la relance) (PMPTR). For the health sector, the Government presented its priorities and asked for development partners’ assistance to increase access of the population to essential health services (EHS) throughout the 515 health zones. Like other partners, the Bank promised to provide technical input and help bridge the financing gap. Increased external support in the coming years, combined with better Government financing, should go some way towards meeting the requirements for achieving progress on the MDGs : Ongoing World Bank-financed projects include: (i) the Emergency Multisectoral Rehabilitation and Reconstruction Project (EMRRP) which is supporting the revitalization/rehabilitation of a total of 67 Health Zones (out of 515 HZ) covering a population of about 8.5 million people; and Page 7 (ii) the multisectoral HIV/AIDS project (to be effective in October 2004). Technical advice is also provided in the context of the Country Status Report – Health. It is anticipated that the external assistance to the health sector could exceed US$200 million annually in the coming years. Combined with increased Government spending, total public spending on health could reach US$4 per capita annually. Although this is some distance from estimates of US$16 per capita needed to reach the MDGs in other countries in the region, it provides a good start, particularly since the bulk of resources are focused on basic services which address the most important causes of morbidity and mortality. Nevertheless, it is clear that even with high rates of economic growth, significant donor assistance will be required to sustain progress over the long term. 4. Description Lending instrument The proposed instrument is a Sector Investment Loan (SIL). Given the weak implementation capacity in the public sector, particularly at the periphery, such an instrument was considered most suited to the proposed project. Its implementation will rely on a strong partnership with NGOs and other implementing agencies. Project development objective and key indicators The Project Development Objective is to significantly improve the availability and utilization of quality essential health services for the population of targeted geographical areas, particularly women and children. This will be achieved by strengthening the existing public health system at all levels, with special attention paid to the district level and the health zone. Improving geographical access, reducing financial barriers to utilization, improving the quality and effectiveness of care, and strengthening the capacities of the front-line service delivery system, are priorities for the project. The project Key performance indicators (KPIs) will be in line with the MDGs. Project components Strategic Approach: The project fits within the strategic framework of the Government’s November 2004 Minimum Partnership Program for Transition and Recovery , which has the objective of revitalizing the health care system in order to achieve progress toward the Millennium Development Goals (MDGs). The Government’s strategy to achieve this objective is twofold: i) improve coverage of basic health services through decentralized support at the Health Zone level and close partnerships with non-governmental actors; and ii) strengthen capacities at all levels, focusing on the main MDG targets (reduce malnutrition, child mortality, and maternal mortality, and combat HIV/AIDS, tuberculosis, malaria, and other priority diseases). The Project builds on the experience of the health component of the Emergency Multisector Rehabilitation and Reconstruction Project, which became effective in 2002 and is ongoing. The health component (IDA contribution of US$ 44 million) supports the development of essential Page 8 health services in 67 Health Zones, as well as technical training institutions and regional drug distribution systems. Implementation is contracted to eight non-governmental agencies working in close collaboration with Ministry of Health structures. Component 1 (US$ 50.0 million): Support to targeted Districts and Health Zones to improve the availability and utilization of essential primary and first-referral health care services while developing the front-line health system. The Project will support the implementation of the Ministry of Health’s (MOH) Essential Package of Health Services in the assisted Health Zones. This will be accomplished through performance-based partnership agreements (PPAs) between the MOH and implementing partners (IPs), mostly but not exclusively, NGOs selected competitively. Implementing partners are expected to support the existing health system - they will not provide services directly . The basic thrust of this component is to allow IPs and their MOH partners at the District and Health Zone levels the flexibility to design and implement programs most adapted to local circumstances, while closely monitoring their performance in achieving project objectives. The project will finance these agreements and the IPs will work in partnership with the MOH (at the central as well as the regional levels) to help attain the following sub-objectives: Improving Availability of Basic Health Services As the burden of disease in DRC falls largely on women and children, the Government strategy emphasizes strengthening maternal and child health services. Therefore, the IPs, through the PPAs, will ensure the provision of the following services at the primary care level: (i) Child preventive health interventions : As DRC has a five-year total grant commitment from the Global Alliance for Vaccines Initiative (GAVI) of US$ 46,230,500; this Project does not propose to fund vaccines. However, it is clear that the national vaccination program is experiencing significant difficulties in ensuring the delivery of vaccines to the Provinces and from there to the Health Zones. In addition, when available, existing cold chain equipment is inadequate. Vaccinations are given as part of pre-school consultation visits to the PHC facilities for prevention services that also include vitamin A supplementation and the distribution of insecticide-treated bed nets (ITNs) for the prevention of malaria. Both of these are essential functions of the health system, and massive increases in the coverage of all three of these interventions will be required if the objectives of this Project are to be reached. (ii) Maternal and neonatal health services : A second package of preventive services involves antenatal care, which has benefits for the mother but has most effect on protecting the health of the child. To reduce the heavy burden of maternal mortality, efforts must be made in two areas: ensuring that a skilled health provider attends every birth and upgrading every first-level hospital to be able to provide emergency obstetrical services. Of course, for women to take advantage of the upgraded services, physical (transport) and financial access needs to be improved. (iii) Integrated Management of Childhood Illnesses (IMCI): Generic WHO protocols for the treatment of acute respiratory infections, diarrhea, fever/malaria, measles, and malnutrition have been adapted for use at first-level health centers and at referral hospitals. IMCI is being Page 9 implemented, albeit slowly, in Health Zones that enjoy external support. This Project would strongly support a vigorously accelerated expansion of these services. To do this, training programs will have to be well planned and adequately funded. The project will also support the implementation of the new policy for the treatment of diarrhea, and the incorporation of new national malaria treatment policies into IMCI guidelines. Finally, it will encourage bringing preventive and curative care as close as possible to communities, such as antibiotic treatment for pneumonia at the community level. (iv) Community-level activities In DRC, most childhood mortality occurs not at the hospital or even at the Health Center, but within the community. The Project will support the development of Community Health Workers CHWs ( relais communautaires) whose functions will include the treatment of diarrhea, pneumonia, malaria, the promotion of family planning acceptance, of the 12 key behaviors included in the Community-IMCI package, and the identification and referral of obstetrical complications to the Health Center or directly to the first-referral hospital. Because CHWs will be volunteer workers, adequate training and supervision, as well as their supply of basic drugs and equipment needs to be provided from the Health Center and the Central Health Zone Office. Finally, a system of performance incentives for the competent delivery of health services at the community level will be considered. The proper management of childhood illnesses and delivery complications cannot be successfully implemented without the presence of strong referral-level facilities. The project will support the development of such a system. Improving Utilization of Basic Health Services In addition to restoring the availability of priority primary health care and minimum referral services in target Health Zones, the project will contribute to reducing financial barriers to utilization, particularly for maternal and child health services. In line with Government’s strategy which involves a partnership between Government, external donors, and the population in financing of basic health services, the project will leave flexibility to implementing partners, in consultation with local authorities, to adopt consultation fees and drug price policies most appropriate to their situation. At the same time, the Project will support improvement in financial management, transparency, and accountability, at the facility and Health Zone levels, as well as improve exemption programs for the poorest. Finally, the Project will include reforms at the National, Provincial, and District levels to increase Government funding for the system – particularly health staff remuneration – and eliminate the current practice of “taxation” of lower levels of the system by the intermediary levels. In addition to cost, issues such as waiting time, the quality of the reception, and the respect accorded to the patient may be barriers to utilization. The project will support activities aimed at improving service quality and health seeking behavior of households. Page 10 Developing the health system Reconstruction and development of the health system in the coming years can build on two fundamental strengths. (i) Decentralized organization into Health Zones, which integrate PHC and first-referral services under one administrative structure. At the same time as supporting basic health services to address the urgent needs of the population, progressively more attention and resources should be devoted to developing the capacities of the system . Health Zone and District authorities need to be more fully involved in allocation and management decisions in order to improve their ownership as well as develop their capacity. The Project will strengthen coordination and supervisory capacities of district and health zone administration by providing training in key areas such as program coordination, financial and personnel management, and monitoring and evaluation. The Project will also focus on improving the technical capacity of front-line health workers, including CHWs, through training and technical assistance. (ii). The second basic strength of the DRC health system is the close integration of private non-profit service providers. In many Health Zones, key facilities, particularly the reference hospital, are run by church-based organizations. This Project builds on this experience and supports performance-based partnership agreements (PPAs) between the MOH and Implementing Partners (IPs) as well as between the IPs and service providers. Component 2 (US$ 8.4 million): Building Capacity for Oversight and Management of the Health System (i) Monitoring and Evaluation . The design of the Project requires an important focus on monitoring and evaluation to assess the performance of the IPs as well as provide constructive feedback and share best practices. Performance-based Agreements between IPs and the MOH will set out the broad goals and strategic directions of the Project (such as described in the sections above), leaving Implementing Partners flexibility in achieving them according to the specific contexts they are working i n. This strategy fits well with DRC’s focus on results, its decentralized health system, and avoids inefficiencies of overly-directive project design. An independent External Evaluation Agency (EEA) will be contracted to measure the performance of the IPs on the basis of a set of agreed indicators, and a financial incentive (bonus) will be tied to their performance. The project will support a baseline study in the target areas as well as a number of M&E activities. See Technical Annex 3 for more details on monitoring and evaluation. (ii) Building capacity for stewardship and strategy development. A major long-term benefit of the performance-based design of the Project is anticipated to be the strengthening MOH ownership and capacity in terms of stewardship of the health system. M & E findings will be regularly shared and discussed, under the leadership of the MOH, during regular “Health Forums” (at least annual) involving the IPs and other sector partners. The Health Forum will be an important accountability mechanism to disseminate findings, lessons, and best practices relevant to implementation of health activities. This component of the Project is designed to provide the tools to the MOH to strengthen its coordination and supervision of IPs (which should Page 11 also spill-over into better management of the implementing partners of other donor programs). In addition, capacity will be strengthened for the MOH to effectively initiate and analyze specific studies of policy importance, such as household out-of-pocket health expenditures, the functioning of user fee exemption systems, and human resources and health labor markets. Component 3 (US$ 3.0 million): Project Coordination The project will strengthen project coordination with an increment in resources required to track progress and carry out (or contract –out) procurement and financial management activities directly associated with project activities. The Project Coordination Unit will be responsible for convening periodic “health forums” to which will be invited all health development partners in the country, particularly those involved in implementation. The PCU will primarily rely on existing MOH staff and avoid the creation of external and parallel structures. External technical support will be contracted on an occasional basis to address the capacity needs of the Unit as well as other parts of the Ministry in areas important to the Project objectives. 5. Financing Source: ($m.) BORROWER/RECIPIENT 0 INTERNATIONAL DEVELOPMENT ASSOCIATION 60 BILATERAL AGENCIES (UNIDENTIFIED) 40 Total 100 6. Implementation 1. Partnership arrangements (if applicable) Preparation of this project was in close cooperation with all development partners supporting DRC. The Partnership for Child Survival supported this project and provided technical input. USAID provided technical support through its partner programs (BASICS and Advance Africa). The choice of the project target zones was made after a thorough consultation with all donors, particularly the EU, USAID, the Belgian Cooperation, and the African Development Bank. 2. Institutional and implementation arrangements Institutional arrangements are based on the following principles: (i) Implementation of project activities at the level of the District 3 will be delegated to Implementing Partners (IPs), such as international NGOs; (ii) Agreements between the IPs and the MOH will be performance-based, prompting all concerned to focus on results and leaving the IPs the flexibility to design implementation mechanisms best adapted to achieve these results; a financial bonus tied to performance indicators provides the incentive for efficient implementation; (iii) Performance- based agreements (PPAs) will be monitored and evaluated by an independent External Evaluation Agency (EEA) which will be internationally recruited on a competitive basis; (iv) The MOH will organize periodic “Health Forums” to disseminate findings of the EEA, to share 3 A District includes 7-12 Health Zones, and Health Zones cover an average of 110,000 people. Page 12 best practices aimed at improving results, and strengthen its stewardship role. Detailed institutional arrangements are described in Annex 6. Role of the various actors Role of the MOH and the PCU: The MOH will have overall responsibility for ensuring successful implementation of the project. An independent PCU will be set up at the Office of the Secretary General of the MOH. It will subcontract implementation of Component 1 (Support to targeted Districts and Health Zones) to implementing partners (IPs), and component 2(i) (M&E) to an External Evaluation Agency (EEA). These constitute about 80% of project activities. Organization of the “Health Forums”, training activities and recruitment of individual consultants will be carried out by the PCU. While the PCU will be responsible for all aspects of project financial management, accounting and audit, it will outsource internal auditing and accounting functions to an international accounting and auditing firm. Two staff from this firm will be located at the PCU premises. The PCU will sign an agreement with BCECO which will act as a service provider for large procurement and some financial management functions, such as disbursement of funds to the IPs. Role of BCECO: An agreement will be signed between the MOH, via the PCU, and BCECO ( Bureau Central de Coordination) whereby BCECO will act as a service provider. BCECO is an institution of the DRC Government which was first established in August 2001 to manage funds under IDA grant H0050. It reports to a Steering Committee chaired by the Minister of Finance. BCECO has demonstrated its ability to effectively carry out procurement and financial management and has sufficient capacity to increase the scope of its activities without being overburdened. BCECO will disburse funds to the IPs after securing the approval of the PCU. It has designated a focal person who will orchestrate all procurement activities that BCECO will carry out for the project. These consist essentially of international recruitment on a competitive basis for IPs (6-7), the EEA (1), and the external auditor (1). Role of the Implementing Partners (IPs): The role of the IPs is to ensure that an essential package of health services is provided in the targeted Districts and Health Zones according to the norms and standards agreed with the MOH. At the same time, they are expected to strengthen the technical capacity of front-line service providers as well as the management skills of local community and administration. As such, they will serve as a catalyst and a facilitator. Performance of the IPs will be measured against pre-established indicators and targets and will be linked to a bonus payment. Because of the focus on outputs rather than inputs, the IPs will be given the autonomy to choose the methods they see fit in order to reach results, within the MOH framework and norms and in accordance with project objectives. Role of the EEA: Lessons learned from the EMRRP show that an independent and transparent M&E system is crucial for successfully attaining desired results. The EEA will have a two-phase contract with the MOH via the PCU. The first phase (under the PPF) consists of carrying out a baseline survey in the target districts, and the second phase consists of carrying out monitoring activities and periodic evaluations of IP performance. It will communicate results of its evaluation to the PCU and in the periodic Health Forums. The EEA will also have a role in building the capacity of the Ministry in this Page 13 area, coordinating in particular with the existing health information system, and assisting in defining specific issues requiring more in-depth study. (See the section on M&E below) The role of the financial auditors is described in the Financial Management section below. A draft operational manual will be discussed during negotiations and finalized by the PCU by effectiveness. 3. Monitoring and evaluation of outcomes/results The principal objective of the Monitoring & Evaluation system is to track progress on the impact and output indicators, and measure periodically the performance of the IPs. A recently-approved PPF will finance baseline measurement of key indicators and periodic evaluations will be conducted during project implementation to track progress and achievement against the baseline levels. A set of key performance indicators was prepared in close collaboration with the MOH and development partners. It covers six project intervention themes: (i) management/organization and finances; (ii) community involvement; (iii) service delivery and health programs; (iv) drugs and supplies; (v) health human resources; and (vi) training, knowledge, skills and attitude. An External Evaluation Agency (EEA) will manage the Monitoring & Evaluation system. It will be recruited internationally and particular attention will be paid to the bidding process to ensure its independence and objectivity. The EEA will: (i) implement a baseline study; (ii) carry out routine assessments and surveys in the project areas (at the levels of the District and Health Zone administrations, health facilities, and communities) to evaluate progress and achievement of intended results by each IP; (iii) communicate its findings to the PCU and during the periodic Health Forum (held every six or twelve months); and (iv) propose the level of bonuses to be attributed annually to each IP. The EEA will also manage special studies to be determined (which may be sub-contracted). Given the difficult terrain and distances in the target project areas, the task of the EEA will be to design a M&E system that is reliable while pragmatic. The M&E system should benefit as much as possible from existing resources, notably the National Health Information System (NHIS) and its surveillance framework for the Districts and Health zones. Once IPs are selected, the PCU will organize a M&E workshop to agree with each IP on the performance targets for each project district. Of course, the baseline measurement results will have an impact on the definition of annual targets. In addition to monitoring and evaluating the performance of the IPs and the project as a whole, the M&E system will have indirect benefits. It will contribute to: (i) strengthening the technical role and operational competency of the NHIS and epidemiological surveillance; (ii) improving MOH knowledge and capacity for effective coordination and supervision of implementing partners; (iii) improving Health Zone management and supervision; (iv) strengthening operational linkages between the various actors at the levels of the Health Zone and District; (v) reinforcing systematic use of clinical guidelines/protocols; and (vi) increase knowledge of and responsiveness to community concerns. With regard to the last point, planned light household surveys will provide reliable data for assessment both of overall results in terms of health Page 14 outcomes and service utilization, and of the extent to which the poorest and most vulnerable have been reached by the project interventions. 7. Sustainability The project supports implementation of Government health strategy and its operational policies and norms; it will facilitate the delivery and utilization of essential packages of primary and first- level referral services to targeted health Districts and Zones, through implementing partners. This approach, followed by all donors, is designed to achieve progress towards the MDGs in a situation of severe capacity constraints. However, the project represents an evolution of the current approach towards a greater focus on development of the capacity of the health system, particularly at the front-line service level. Project design reflects this in a number of ways: i) Targeted Health Zones are grouped in Districts to facilitate development of this intermediary level of the health system. ii) Project activities at the Health Zone level include significant capacity-building and training of Zone health administration. iii) The project supports significant technical in-service training of front-line health service personnel. iv) The liaison between IPs and health authorities at all levels is designed to strengthen Government ownership and capacity to fulfill its stewardship role. v) The monitoring and evaluation (M&E) component of the project is designed to increase Government capacity in this area at all levels, as well as provide the Ministry with information and tools for effective supervision of IPs. The last point is related to the strategy of performance-based contracting with IPs. This builds on the Government’s long experience with public-private partnerships, including church-based organizations, and more recently, humanitarian NGOs. The approach allows government to evaluate and supervise IPs on the basis of measurable results. In particular, regular “Health Forums” involving Government, IPs, and other sector partners, are planned to share M&E results, facilitate coordination and sharing of lessons, and strengthen the Government’s capacity and experience with stewardship of the sector. Consistent with the decentralized health system, the PCU at the central level will be small and staffed with current civil servants and so will have no effect on future wage obligations. Similarly, at the District and Zone levels, staffing needs are expected to be met by existing cadres, either currently in place in target areas, or to be reallocated. Shortage of skilled staff is not expected to be a concern during the timeframe of the project, as the health system country- wide will just be starting to recover its past capacity. In the past, the development of the system, centered on Health Zones, involved a partnership between external donors, which were to finance investment, the Government, which was to finance recurrent costs, largely wages, and the population, who were to support part of drug costs in particular. This broke down in the 1990s, leaving households with most of the burden of financing health services. The project is a step towards reviving this partnership, but one of its primary objectives is to increase basic health service utilization – in particular by reducing Page 15 financial barriers. This is done, in essence, by subsidizing recurrent costs, which recognizes that: i) although Government health spending has been increasing, it will not be in a position to fully meet the recurrent costs of the health system in the medium term; ii) in one of the poorest countries of the world, most households cannot continue to pay significant proportions of their income for health services; and iii) like in other poor countries, achieving progress towards the MDGs will require substantial support from the international community. This support for basic services is consistent with the Government’s medium-term fiscal framework, which recognizes the requirement for significant external financing in the coming years ($US 1.5 billion in 2005, for example). (IMF, 2004). At the same time, the project does not attempt to meet the full costs of health services, as Government will finance, in particular, the wages of health personnel. Health Zone authorities and IPs will have flexibility in terms of setting user fees and drug prices according to local circumstances and in a balanced manner designed to achieve the results that will be measured – particularly increased service utilization, including by the poorest. 8. Lessons Learned from Past Operations in the Country/Sector The project has incorporated several lessons from (i) recent Bank operations in post-conflict countries such as Afghanistan, Cambodia, East Timor, and Mozambique; and (ii) from earlier Bank operations in DRC, particularly the EMRRP. Bank operations in post-conflict countries: (i) A large role for NGOs in support to service delivery can overcome capacity constraints in post-conflict countries. At the same time it is important to develop Government capacity, with regard to both coordination and management of non- governmental partners and to the capacities of the front-line service provision system. This two-track approach is being adopted here, where capacity constraints are significant, but the existing health system, particularly at the local level, provides a good foundation for reconstruction. (ii) A strong PCU at the central level, and strengthened health authorities at the local level, are important to effectively manage these partnership agreements and to ensure ownership of the MOH at all levels. This project will support adequate staffing and develop capacity within the PCU, will ensure that it has the necessary resources to play its role effectively, and has a significant focus on capacity building at the District and Health Zone levels. Bank operations in DRC (i) One advantage of NGOs is their ability to obtain results quickly, because of their “agility”, relative to heavy Government bureaucracy. It’s important that once selected, they are allowed to continue to operate in the same manner; otherwise we would run the risk of paralyzing them. Instead of insisting on additional or new Page 16 procedures, the project will insist on performance and results and will build-in the right incentives to shift the focus from inputs to results. (ii) Some NGOs are effective in a limited geographical area or limited set of tasks. If asked to expand their coverage geographically or technically, they may fail to produce results. The project will carefully choose, on a competitive basis, the performing IPs and an exit strategy for non-performing ones will be clearly included in the PPAs. (iii) It is key to the success and sustainability of the project to empower the technical ministry. Unlike in the EMRRP, the MOH is the agency responsible for the oversight and management of this project. It will be strengthened to play its expected role. Flexibility in terms of implementation must be accompanied by effective and timely monitoring and evaluation of implementing partner performance. Experience has shown that obtaining reliable and timely data, analyzed appropriately, is not easy in the context of DRC, so this aspect must receive sufficient attention and resources. 9. Safeguard Policies (including public consultation) Safeguard Policies Triggered by the Project Yes No Environmental Assessment ( OP / BP / GP 4.01) [X] [ ] Natural Habitats ( OP / BP 4.04) [ ] [X] Pest Management ( OP 4.09 ) [ ] [X] Cultural Property ( OPN 11.03 , being revised as OP 4.11) [ ] [X] Involuntary Resettlement ( OP / BP 4.12) [ ] [X] Indigenous Peoples ( OD 4.20 , being revised as OP 4.10) [ ] [X] Forests ( OP / BP 4.36) [ ] [X] Safety of Dams ( OP / BP 4.37) [ ] [X] Projects in Disputed Areas ( OP / BP / GP 7.60) * [ ] [X] Projects on International Waterways ( OP / BP / GP 7.50) [ ] [X] 10. List of Factual Technical Documents 11. Contact point Contact: Eva Jarawan Title: Lead Health Specialist Tel: (202) 473-4028 Fax: (202) 473-8107 Email: Ejarawan@worldbank.org * By supporting the proposed project, the Bank does not intend to prejudice the final determination of the parties' claims on the disputed areas Page 17 12. For more information contact: The InfoShop The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 458-5454 Fax: (202) 522-1500 Web: http://www.worldbank.org/infoshop