PROJECT INFORMATION DOCUMENT (PID)



PROJECT INFORMATION DOCUMENT (PID)

APPRAISAL STAGE

Report No.: AB7347

|Project Name |Reproductive and Child Health Project - Phase 2, Second Additional Financing |

|Region |AFRICA |

|Sector |Health (100%) |

|Project ID |P132753 |

|Borrower(s) |GOVERNMENT OF SIERRA LEONE |

|Implementing Agency |Ministry of Health and Sanitation and Ministry of Finance and Economic Development |

|Environment Category |[ ] A [X] B [ ] C [ ] FI [ ] TBD |

|Date PID Prepared |May 10, 2013 |

|Date of Appraisal Authorization |June 14, 2013 |

|Date of Board Approval |July 23, 2013 |

1. Country and Sector Background

Sierra Leone has a per capita Gross National Income (GNI) of US$300. Following a brutal decade-long civil war which killed 20,000 people and displaced half the population, Sierra Leone has been on a path of reconciliation, reconstruction, and stabilization of its economy and governance systems. Since 2002, the country has held parliamentary, presidential and local elections which have all been deemed free and fair. Recent political events provide good reason for optimism that a pluralistic democratic system is now well established.

Sierra Leone’s post-conflict economic performance has been robust. Sierra Leone’s recovery, which began in 2000, continued for a ninth unbroken year into 2008 when real GDP grew by an estimated 5.5 percent despite an unusual simultaneous spike in the world prices of food and fuel commodities. However, the impact of the global recession has been far deeper and faster than expected. Sierra Leone’s growth for 2009 has been estimated at 4.5 percent.

Sierra Leone’s health indicators are grim but have shown signs of improvement over the past three years. Sierra Leone has a life expectancy of 47 years, an infant mortality rate of 89 per 1000 live births, and a maternal mortality ratio of 857 per 100 000 live births. Each year, about 9 percent of children die before their first birthday and 1 of every 8 children dies before his/her fifth birthday; up to 40 percent of these deaths occur in the first month of life.

Utilization of key, low cost and highly effective health services is low. The main constraints are (i) insufficient human resources; (ii) inadequate Government financing which puts the burden of payment on patients; (iii) weak institutional capacity; (iv) lack of availability of essential drugs and basic medical equipment; and (v) cultural barriers. The government is addressing some of these key issues as part of its plan to remove formal user charges for maternal and child health care services on April 27, 2010 in public facilities.

2. Objectives

The objective of Phase 2 of the RCH Project is to increase utilization of a package of essential health services by pregnant women and children under the age of five.

3. Rationale for Bank Involvement

The rationale for the proposed Second Additional Financing (AF2), is to help finance the costs associated with the implementation of additional activities that scale up the impact and development effectiveness of the ongoing Reproductive and Child Health Project – Phase 2’s (Grant No: TF096812) in line with OP/BP 10.00

AF2 would help finance the costs associated with the implementation of additional activities that scale up the ongoing Reproductive and Child Health Project – Phase 2’s impact and development effectiveness (Grant No: TF096812) in line with OP/BP 10.00. A request for additional financing was received from the Ministry of Finance and Economic Development on June 13, 2013 to support strengthening of the existing primary health care performance-based financing (PBF) by extending this to private primary health care (PHUs) providers and scaling up the performance-based financing mechanism (PBF) from two hospitals to six. It will also strengthen prevention services by supporting procurement and distribution of malaria bed nets. AF2 will also support the improvement of the capacity of the Ministry of Health and Sanitation to carry out its oversight functions, as well as contribute technical and operational assistance for the introduction of a social health insurance scheme for Sierra Leone.

4. Description

The second additional financing would be used both for project scale-up and to support restructuring to address recently identified high priority interventions as outlined below. The activities are consistent with the PDO of RCHP 2, and with the Country Assistance Strategy (CAS) for Sierra Leone. The proposed changes would increase the Bank’s financial contribution to the existing project activities from US$25.69 million, which was the amount following the first additional financing, to US$43.69 million (ACGF: US$25.69 million + IDA: US$13.00 million + HRITF: US$5.00 million), and extending the closing date of the project, for the first time, by 36 months through to October 31 2016.

The results framework retains the same PDO and intermediate outcome indicators and additional ones have been introduced for the new activities. Some targets have also been changed to reflect the additional funding and implementation period. AF2 will finance activities under sub-components 1A, 1B, IC and 1D, and introduce sub-component 2.3 for technical Assistance.

Sub-component 1.A: The proposed AF2 will be used to provide essential inputs which will allow hospitals and PHUs to provide PBF services effectively, including medical equipment for hospitals ($3.0 million) and initial funding for accommodation of medical staff. Funding beyond the initial allocation will come from the RBF allocation.

Sub-component 1.B: AF2 would also be used to (i) strengthen the existing primary health care PBF by extending to private primary health care (PHUs) providers and (ii) scale up the performance-based financing mechanism (PBF) from two hospitals to six or eight hospitals.

The PHUs PBF is focused on six key maternal and child health services. These services are: (i) family planning, (ii) antenatal consultations, (iii) facility skilled deliveries, (iv) postnatal consultations, (v) full vaccination of children under one, and (vi) outpatient consultations for children under five years. The quantity of each service is adjusted to clinical quality factor scaled from 0-1. These clinical quality criteria are the standards for delivering primary health care services. A general cross cutting quality score is applied to ensure the health provision system at facility level as a whole is strengthened and all services are improved. The cross cutting criteria are: (i) attendance at work, (ii) timeliness of submission of HMIS Report, (iii) functioning health management committee, (iv) display of updated information, (v) appropriate record keeping, (v) Cleaning of facility, (vi) good drugs management, (vii) no stock-out of essential drugs and (ix) appropriate medical waste management procedures in place and being observed.

The PBF was introduced in two hospitals (Princess Christian Maternity Hospital and Ola During Children Hospital) in 2012. The purpose was to improve the quality of services through the following services: (i) general organization, (ii) human resources management, (iii) financial management, (iv) pharmaceutical management and preventing drugs stock out, (v) hygiene and sanitation, (vi) patient care, (vii) health care services and (viii) laboratory.

Reports indicate that the introduction of the PBF has contributed immensely to the overall service uptake and improvement of quality of services delivered at all levels countrywide. The reports particularly reveal the improvement in uptake and quality of the six identified indicators. The PBF also remains a key supportive supervision and monitoring tool both at central and district levels. As health facilities’ verified data are the basis of the performance payment, the quality and timeliness of reporting has improved rapidly. However the PBF scheme would require further strengthening both in scale and depth to foster innovations at facility level which are directly correlated with improved quality and access to services. To strengthen procurement of essential drugs, technical support was provided to include prevention of stock-outs as an explicit criterium for PBF. However despite these measures hospitals, clinics, and district facilities still face some stock-out. AF2 will explore alternative options for all facilities including hospitals and PHUs to acquire these drugs in case of non-availability at national level, and will also assist in ensuring that facilities for the storage of drugs and medical supplies are available at the district level to make them more readily available to both hospitals and PHUs in each district. In this regard, these interventions will complement the efforts already being supported by UNICEF in strengthening the supply chain at the national level.

PBF has shown promise and AF2 will build on this by both deepening quality and coverage. This will be expanded to include other private PHUs and up to six additional hospitals (3 Regional and 3 District Hospitals). An impact evaluation will also be conducted to provide evidence on PBF’s contribution and also to aid the decision on sustainability measures of using the current government budget for PBF. The availability of medical equipment has been noted as a barrier to further performance improvement in the existing hospitals and this also needs to be addressed in the additional 4 hospitals which are going to participate in RBF. The lack of functioning medical equipment, specifically in the operating rooms and recovery areas as well as in laboratories, is placing limits on the ability of facilities to meet increased patient demand. Just as the initial roll-out of RBF provided up-front input funding to allow facilities to provide the required services, similar preparatory funding is needed for the hospitals that are being added.

Sub-component 1C: AF2 will fund the procurement and distribution of additional Long Lasting Impregnated Nets (LLINs) to contribute to the replacement policy following the national malaria campaign in 2010. Sierra Leone completed the LLIN universal campaign in 2010 following which overall net coverage for at least one LLIN per household was 98%. Given the degradation rate and population growth, there is need to ensure that all new pregnancies and children under one year continue to be protected by LLINs. This will ensure sustained impact on morbidity and mortality reduction. This action will also contribute to sustain the coverage of LLINs and maintain at levels that offer population protection. The additional financing will support procurement and distribution of LLINs through routine systems such as ANC delivered at health facilities and on national immunization days. The AF2 will contribute $3.0 million for which at global pricing of $5.8 per LLIN inclusive of distribution cost, 517,200 LLINs will be procured and distributed. These nets will be procured through UNICEF.

Sub-component 1D: This sub-component is ongoing, and supports the implementation of the PBF program, as well as project management generally. With the extension of both time and PBF scope, additional funds are needed for this activity including paying for the external verification agency.

Sub-component 2.3: AF2 will also support a technical assistance program. It will build on the support provided to date through various World Bank missions and will finance specific activities in the areas of: (a) organization and management, including the establishment of the Integrated Health Project Administration Unit (IHPAU); (b) technical and logistical support for the operationalization of the Health Services Commission; (c) assistance in the review of the legislative and regulatory framework for health; (d) support for the improvement of health management information systems; and, (e) support in the area of health financing focusing on sustainability of the free health care initiative (FHCI) and the development of a social health insurance scheme in Sierra Leone. The development of the IHPAU, which will be integrated into the operating structures of the MOHS, will help to consolidate the management and oversight of all externally financed projects, leading to more effective planning, control and implementation.

|Financing Source: |($m.) |

|Recipient |0.0 |

|IDA |13.00 |

|Health Results Innovation Trust Fund (HRITF) |5.00 |

| | |

| Total |18.00 |

5. Implementation

The implementation arrangements for the proposed Additional Financing would be the same as for the existing parent project. The Chief Medical Officer (CMO) of the MoHS is the Project Director and is providing the technical oversight for the project. He works closely with the Directorate of the LGFD of the MoFED to ensure cohesion between the activities in component 1, which is implemented by the Local Councils, and those in component two, which are implemented by the MoHS.

Component 2 is implemented by existing staff of the Ministry of Health and Sanitation (MoHS). There is no separate Project Coordination Unit. The Director of the RCH Directorate is coordinating the implementation of the component within the MoHS. The Directorate of Planning and Information leads the implementation of the preparation of the central level annual plan and the monitoring and evaluation activities of the MoHS. The Permanent Secretary supervises the activities of the financial management, procurement and internal audit functions under the project.

6. Sustainability

Financial sustainability is likely. Sierra Leone is one of a handful of countries that has eliminated user fees and in return, has been guaranteed additional funding. Government allocations are also increasing and there is room for improvements in the execution and efficiency of government spending. Development partners are embarking on a harmonized approach which will make it possible to reallocate donor funds between activities within the overall health budget if necessary. Government financing is also expected to increase as the country returns to a positive growth scenario.

Institutional sustainability is also likely. Implementation of services at the district level is well established. It is likely that capacity building and management reforms will be sustained once established under the project. Investments in medical training are also likely to be sustained since one of the objectives is to use foreign professors until local university staff can be trained for these positions. The Bank will continue to provide technical assistance during the life of the project on human resources.

7. Lessons Learned from Past Operations in the Country/Sector

Lessons learned from Phase 1 have been incorporated into this operation. Phase 1 was designed to help improve health targets, and also to identify bottlenecks and capacity building needs in Phase 2. It contributed to strengthening the readiness for Phase 2 by demonstrating the feasibility of the key components of the project: (i) the comprehensive district health plans which were prepared by the Local Councils in a consultative, bottom up manner; (ii) the Sub-Grant Agreement which formalized the collaboration among MOHS, MOF, and the Local Councils for implementation of the district health plan; and (iii) the financial arrangements by which funding for LCs flow through the LGFD and funding for the key policy, technical oversight, supervision, and M&E responsibilities of the MOHS flow through the MoHS.

Lessons learned from other projects in Sierra Leone have also been incorporated into this operation including: (i) focusing on a fewer monitorable outcomes; (ii) keeping the design simple and selective in what is financed; and (iii) using a phased approach so that capacity issues could be addressed early on.

Finally, lessons learned from World Bank support to the health sector have been incorporated into the project.[1] For example, the project supports an integrated approach by providing block grants to LCs rather than earmarked funding for specific programs. Grants to the LCs currently include a performance element which is increasing utilization and quality of health services in Sierra Leone, Rwanda and Burundi. Finally, the parent project is addressing and the AF will continue to address some of the key HR issues by financing pre and post graduate training.

8. Safeguard Policies (including public consultation)

No new safeguard policies are triggered under the proposed Additional Financing. The parent project triggered the World Bank’s Environmental Assessment due mainly to the generation of biomedical waste health facilities. Accordingly, the Project is using the updated Environmental and Social Management Framework (ESMF) which includes a Medical Waste Management Plan (MWMP) of the Additional Financing for the Health Sector Reconstruction and Development Project. The existing MWMP is considered to be sufficient for the second additional financing activities. Accordingly, it was resubmitted to the Bank and re-disclosed in-country on June …., 2013, and at the InfoShop in June …, 2013. The MoHS Environmental Health and Sanitation Unit and the Medical Waste Management Units are responsible for ensuring that all health facilities comply with the MWMP as is currently the case. Local Council Environmental Committees is also receiving training in medical waste management in order to improve their monitoring capacity.

| |Yes |No |

|Safeguard Policies Triggered by the Project | | |

|Environmental Assessment (OP/BP 4.01) |[X] |[ ] |

|Natural Habitats (OP/BP 4.04) |[ ] |[X] |

|Pest Management (OP 4.09) |[ ] |[X] |

|Physical Cultural Resources (OP/BP 4.11) |[ ] |[X] |

|Involuntary Resettlement (OP/BP 4.12) |[ ] |[X] |

|Indigenous Peoples (OP/BP 4.10) |[ ] |[X] |

|Forests (OP/BP 4.36) |[ ] |[X] |

|Safety of Dams (OP/BP 4.37) |[ ] |[X] |

|Projects in Disputed Areas (OP/BP 7.60)* |[ ] |[X] |

|Projects on International Waterways (OP/BP 7.50) |[ ] |[X] |

9. List of Factual Technical Documents

Technical Documents

Child Survival and Maternal Mortality Reduction in Sierra Leone: A Situational Analysis. June 2006. MoHS/UNICEF

Monitoring the Situation of Children and Women: Findings from the Sierra Leone Multiple Cluster Survey 2005. Preliminary Report. August 2006. Statistics Sierra Leone and UNICEF.

Primary Healthcare in Sierra Leone: Clinic Resources and Perceptions of Policy after One Year of Decentralization. June 2007. IRCBP Evaluations Unit.

Ministry of Health and Sanitation. Comprehensive National Health Plan 2009. Draft November 2008.

Comprehensive Local Government Performance Assessment System (CLoGPAS) in Sierra Leone. Round 1 Field Instruments, November 2006. IRCBP.

Nationwide Needs Assessment for Emergency Obstetrics and Newborn Care Services in Sierra Leone. August 2008. Reproductive and Child Health Program, MoHS

IRCBP Evaluations Unit (May 2008), Report on the IRCBP 2007 National Public Services Survey Public Services, Governance, Dispute Resolution and Social Dynamics

The Anti-Corruption Commission. Recommendations for Reform: Towards a Better Health Care Delivery System, (estimate 2008/2009)

Government of Sierra Leone. Ministry of Health and Sanitation. National Health Sector Strategic Plan 2010-2015. Draft, April 2009.

Program Documents from other Partners

African Development Fund. Sierra Leone: Proposal for an ADF Grant of US$17,000,000 To Finance the Strengthening District Health Services Project (Health II). April 29, 2005.

DFID. DFID Support to the Government of Sierra Leone’s Reproductive and Child Health Strategy (2008-2012). January 2009.

UN Joint Program Document in Support of the Reproductive and Child Health Strategic Plan for Sierra Leone; March 2008.

10. Contact point:

Name: Evelyn Awittor

Title: Sr Operations Officer (Health)

Tel: 233 302 4169

Fax: 233 302 227887

Email: Eawittor@

Implementing Agency:

Ministry of Finance and Economic Development and Ministry of Health and Sanitation

Contact Person: Edmund Koroma

Financial Secretary

Ministry of Finance and Economic Development

Telephone No.: +232 22-222-211

Fax No.: +232 22 228 472

Email: ekoroma@.sl

11. For more information contact:

The InfoShop

The World Bank

1818 H Street, NW

Washington, D.C. 20433

Telephone: (202) 458-4500

Fax: (202) 522-1500

Email: pic@

Web:

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[1] World Bank, Independent Evaluation Group. Improving Effectiveness and Outcomes for the Poor in Health, Nutrition, and Population: An Evaluation of World Bank Group Support Since 1997.

* By supporting the proposed project, the Bank does not intend to prejudice the final determination of the parties' claims on the disputed areas

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