-
Document of
The World Bank
FOR OFFICIAL USE ONLY
Report No: 66702-BJ
PROJECT PAPER
ON A
PROPOSED ADDITIONAL GRANT
IN THE AMOUNT OF SDR 6.5 MILLION
(US$10 MILLION EQUIVALENT)
AND
RESTRUCTURING
TO THE
REPUBLIC OF BENIN
FOR THE
HEALTH SYSTEM PERFORMANCE PROJECT
February 17, 2012
This document has a restricted distribution and may be used by
recipients only in the
performance of their official duties. Its contents may not
otherwise be disclosed without World
Bank authorization.
Pub
lic D
iscl
osur
e A
utho
rized
Pub
lic D
iscl
osur
e A
utho
rized
Pub
lic D
iscl
osur
e A
utho
rized
Pub
lic D
iscl
osur
e A
utho
rized
-
2
CURRENCY EQUIVALENTS
(Exchange Rate Effective 01/31/2012)
Currency Unit = CFA Franc (XOF)
XOF 507.02 = US$1
SDR 0.65 = US$1
FISCAL YEAR
January 1 – December 31
ABBREVIATIONS AND ACRONYMS
ACT Artemisinin-based combination therapy
AF Additional Financing
BCC Behavior Change Communication
BCEAO Banque Centrale des Etats de l’Afrique de l’Ouest
CAME Central Drugs Procurement Unit
CAS Country Assistance Strategy
CBO Community Based Organization
CSR Country Status Report
DHS Demographic and Health Survey
EEZS Equipe d'Encadrement de la Zone de Santé
FMCI Free Malaria Care Initiative
GAVI Global Alliance for Vaccines and Immunization
GoB Government of Benin
GSM General Secretary of the Ministry
HEF Health Equity Fund
HF Health Facilities
HSPP Health System Performance Project
ICB International Competitive Bidding
IDA International Development Association
IPT Intermittent Preventive Treatment
ISR Implementation Status and Results
M&E Monitoring and Evaluation
MDG Millenium Development Goal
MoH Ministry of Health
MWMP Medical Waste Management Plan
NCB National Competitive Bidding
NMCP National Malaria Control Program
OBD Output-based Disbursement
PCU Project Coordination Unit
-
3
PDO Project Development Objective
PMI President's Malaria Initiative (USAID)
PNDS Plan National Developpement Sanitaire
RBF Results-Based Financing
RDT Rapid Diagnostic Test
RVP Regional Vice President
SOE Statement of Expenses
SWAp Sector Wide Approach
TF Trust Fund
USD United States Dollars
WB World Bank
Vice President: Obiageli K. Ezekwesili
Country Director: Madani M. Tall
Sector Director Ritva Reinikka
Country Manager Olivier Frémond
Sector Manager: Jean-Jacques de Saint-Antoine
Task Team Leader: Christophe Lemière
-
4
REPUBLIC OF BENIN
HEALTH SYSTEMS PERFORMANCE PROJECT
TABLE OF CONTENTS
Project Paper Data Sheet 5
Project Paper
I. Introduction 8
II. Background and Rationale for Additional Financing 9
III. Proposed Changes 12
IV. Appraisal Summary 19
Annexes
1. Revised Results Framework and Monitoring Indicators 24
2. Operational Risk Assessment Framework 36
3. Costs of the package of the Free Malaria Care Initiative
(FMCI) 39
4. Implementation arrangements 41
5. Control arrangements 45
-
5
REPUBLIC OF BENIN
HEALTH SYSTEMS PERFORMANCE PROJECT
ADDITIONAL FINANCING AND RESTRUCTURING
DATA SHEET
Basic Information - Additional Financing (AF)
Country Director: Madani M. Tall
Sector Director: Ritva Reinikka
Sector Manager: Jean-Jacques de Saint-
Antoine
Team Leader: Christophe Lemière
Project ID: P129024
Expected Effectiveness Date: July 31st,
2012
Lending Instrument: SIL
Additional Financing Type: Scale-Up
and Restructuring
Sectors: HNP
Themes: Health system performance
(67%); Child health (33%)
Environmental category: B - Partial
Assessment
Expected Closing Date: Dec 31, 2015
Joint IFC:
Joint Level:
Basic Information - Original Project
Project ID: P113202 Environmental category: B- Partial
Assessment
Project Name: Health System
Performance
Expected Closing Date: Dec 31, 2015
Lending Instrument: SIL Joint IFC:
Joint Level:
AF Project Financing Data
[ ] Loan [] Credit [ X] Grant [ ] Guarantee [ ] Other:
Proposed terms:
AF Financing Plan (US$m)
Source Total Amount (US $m)
Total Project Cost:
Cofinancing:
Borrower:
Total Bank Financing:
IBRD
IDA
New
Recommitted
US$10 million
US$10 million
Client Information
Recipient: Republic of Benin
Responsible Agency: Ministry of Health
Contact Person: Mr Valere Goyito, General Secretary
Telephone No: +229 21 33 21 41
Fax No.:
Email: [email protected]
mailto:[email protected]
-
6
AF Estimated Disbursements (Bank FY/US$m)
FY 12 13 14 15 16
Annual 1.0 5.0 4.0 0 0
Cumulative 1.0 6.0 10.0 0 0
Project Development Objective and Description
Original project development objective: The first PDO consists
in increasing the coverage of
quality maternal and neonatal health care services in targeted
districts. This PDO is broken down
in two intermediate outcomes: (i) improving health facilities
performance through Result-Based
Financing (RBF); and (ii) enhancing financial accessibility to
these health services. The second
PDO is to strengthen the institutional capacity of the Ministry
of Health.
Revised project development objective The objectives of the
Project are (i) to increase coverage of quality maternal, neonatal
and child
health care services in the Targeted Areas, and (ii) to
strengthen the institutional capacity of the
MoH.
Project description
Under the original Project, the first component aims to: (i)
improve performance of health
facilities through a Result-Based Financing (RBF) mechanism;
(ii) strengthen capacities of the
Ministry of Health to facilitate and to monitor the
implementation of this RBF mechanism; and
(iii) support the recruitment of specialist doctors in the
target districts.
The second component aims to increase financial accessibility of
health care services, by: (i)
strengthening the existing process for identifying the poorest
and for exempting them from
health user fees; (ii) strengthening health services in 4 of the
target districts; (iii) funding free
malaria care for pregnant women and under five children; and
(iv) supporting the development
of a universal health care insurance system.
The third component aims to strengthen capacities of the
Ministry of Health in planning,
budgeting, management and monitoring and evaluation.
Activities supported by this Additional Financing (AF) will fall
under Components 1 and 2 to
enhance financial accessibility of health care services through
support to implementation of the
Free Malaria Care Initiative (FMCI) launched by the Government
of Benin in October 2011. In
the eight health districts of the Health System Performance
Project (HSPP), additional activities
will comprise: (i) Procurement of goods included in the four
packages of the FMCI, including
Artemisinin-based combination therapy (ACTs), Rapid Diagnostic
Test (RDTs) and treatment
kits; (ii) reimbursement of non procurable costs associated with
the four packages of the FMCI
through an output-based disbursement mechanism (i.e.
Result-Based Financing); and (iii)
Communication, information and training activities as described
in the strategic FMCI
document.
Safeguard and Exception to Policies
-
7
Safeguard policies triggered:
Environmental Assessment (OP/BP 4.01)
Natural Habitats (OP/BP 4.04)
Forests (OP/BP 4.36)
Pest Management (OP 4.09)
Physical Cultural Resources (OP/BP 4.11)
Indigenous Peoples (OP/BP 4.10)
Involuntary Resettlement (OP/BP 4.12)
Safety of Dams (OP/BP 4.37)
Projects on International Waterways (OP/BP 7.50)
Projects in Disputed Areas (OP/BP 7.60)
[X]Yes [ ] No
[ ]Yes [ X] No
[ ]Yes [ X] No
[ ]Yes [ X] No
[ ]Yes [ X ] No
[ ]Yes [ X ] No
[ ]Yes [X ] No
[ ]Yes [X ] No
[ ]Yes [ X ] No
[ ]Yes [X ] No
Does the project require any waivers of Bank policies?
Have these been endorsed or approved by Bank management?
[ ]Yes [X ] No
[ ]Yes [ ] No
Conditions and Legal Covenants:
Financing Agreement
Reference
Description of Condition/Covenant Date Due
4.01(a) The Recipient has adopted a revised Procedures
Manual, in form and substance satisfactory to
the Association, to incorporate the requisite
guidelines and procedures for the activities
under Parts A.1 (III), B4 and B5 of the project
Effectiveness
4.01(b) The amendment to the Trust Fund Grant
Agreement has been executed and delivered
Effectiveness
Section II, B.2 The Recipient shall install and make
operational
in the General Secretariat, no later than two (2)
month after the Effective Date, an accounting
system software for the Project which is
acceptable to the Association.
No later than two
(2) month after the
Effective Date
Section II, B.2 The Recipient shall appoint, no later than
two
(2) months after the Effective Date, financial
auditors in accordance with the provisions of
Section III of this Schedule.
No later than two
(2) month after the
Effective Date
Section V.1 The Recipient shall, no later than twelve (12)
months after the Effective Date, adopt a strategy
for funding the FMCI that is in form and
substance acceptable to the Association.
No later than
twelve (12) months
after the Effective
Date
-
8
REPUBLIC OF BENIN
HEALTH SYSTEMS PERFORMANCE PROJECT
I. INTRODUCTION
1. This Project Paper seeks the approval of the Executive
Directors to restructure and provide an additional grant in the
amount of SDR 6.50 million (USD 10 million equivalent)
to the Republic of Benin for the Health System Performance
Project (HSPP) (Grant H564-BJ).
This additional financing (AF) is in response to the Government
of Benin’s (GoB) request to
support implementation of the recently launched national Free
Malaria Care Initiative (FMCI)
for pregnant women and children under five. With the AF, the
total grant of HSPP would come
to USD 43.8 million.
2. In Benin, malaria is endemic nationwide and is a major cause
of morbidity and mortality, affecting children under five and
pregnant women in particular. For example,
data from the 2006 Demographic and Health Survey (DHS) show that
among children the age of
6- 59 months old, 78% had anemia, which is likely to be caused
by malaria. 26.1% of all patients
and 36.7% of under-five children are dying from severe malaria
in health facilities according to
the Health Statistic Directory 2010. It is also reported to
account for 40% of outpatient
consultations and 25% of all hospital admissions. Furthermore,
financial access to malaria care
has been a major concern in Benin. Evidence shows indeed
significant difference in access to
malaria drugs between wealth quintiles. For example, among
under-five children who had fever,
51% from the wealthier quintile took malaria drugs the same day
or the day after fever, as
compared to only 31.2% from the poorest quintile (DHS 2006).
3. The FMCI was launched by the GoB in October 2011, with an aim
to remove user fees for simple and severe malaria cases for
vulnerable groups. The strategy prioritizes
pregnant women and under-five children, considered the
vulnerable groups at most risk in the
country. As proven in other countries, large-scale malaria
control (including high coverage with
effective prevention and treatment) has the potential to cut
overall child mortality by 20-25% and
deaths attributable to malaria by up to 80%. Furthermore, as
households contribute up to 42% of
total health expenditures in the public sector, the FMCI could
have significant impact on
coverage and accessibility to maternal and child health
services. This initiative would also
enhance health system performance through supporting
improvements in malaria cases
management, supplying of drugs and commodities, quality controls
and a better use of the
referral health system.
4. The proposed AF would strengthen and expand the impact and
development effectiveness of the HSPP, which aims at increasing the
coverage of quality maternal and
neonatal services and enhance financial accessibility to health
services. Indeed, by removing
financial barriers to access malaria care for two vulnerable
groups (pregnant women and under-
five children), the proposed AF would contribute to improved
maternal and child health
outcomes in Benin. This AF is in compliance with (ii) of OP/BP
13.20, as it proposes the
-
9
implementation of additional or expanded activities that scale
up a project’s impact and
development effectiveness.
II. BACKGROUND AND RATIONALE FOR ADDITIONAL FINANCING IN THE
AMOUNT OF US$10 MILLION
Free Malaria Care Policy
5. Benin officially launched its FMCI on October 4th 2011 to
radically enhance financial accessibility for malaria care to
vulnerable groups. The FMCI removes user fees for
simple and severe malaria interventions through four packages
that include diagnostics,
treatment, exams and visits/hospitalization for: (i) simple
malaria for under-five children; (ii)
severe malaria for under-five children; (iii) simple malaria for
pregnant women; and (iv) severe
malaria for pregnant women. Annex 3 describes the content and
average cost of these four
packages. While the packages are focused on diagnostic and
treatment function, the Government
is taking measures to ensure that prevention remains a priority.
Bednets distributions, Behavior
Change Communication (BCC), capacity building and other
functions are supported from their
own resources or other donor contributions.
6. Recent fiscal deterioration, exacerbated by global economic
slowdown, creates a challenge for the Government of Benin to cover
the entire cost of this new policy. An
estimated cost of implementing this Strategy nationwide is
approximately USD 19 million per
year (see Annex 3 for details of calculations). Other donors,
such as USAID, are planning to
provide some financing (under parallel financing) to support the
initiative. However, available
estimates to-date shows that the required costs far exceed
available resources. The proposed AF
intends to bridge some of this financial gap by covering the
cost of four packages in eight of the
34 health districts for a period of two years, bringing an
important contribution to the first step of
rolling out the policy nationwide. Given that the Government has
maintained active dialogue
with other donors, it is expected that the Bank’s financing will
serve as a catalyst to mobilize
additional resources for this initiative in the medium- and
long-term.
7. The FMCI will be fully integrated in the national health
system. Institutionally, the initiative will be managed by the
National Malaria Control Program (NMCP). The NMCP would
be responsible for implementation of the policy at both central
and local levels. At district and
community levels, District Health Management Teams (i.e. Equipe
d’Encadrement de la Zone
Sanitaire) and mayors would be in charge of monitoring FMCI
implementation. To avoid any
negative impacts of this new policy on service delivery, some
mitigation measures would be
implemented such as offsetting revenues loss for health centers
(given that they can no longer
charge malaria drugs), quality controls on produced services, as
well as provision of bonuses for
health workers to cope with the expected increased workload.
-
10
Other Free Care Policies
8. Benin has already implemented several user fees exemptions
policies, such as Free C-Section and Free Health Care for the
Poorest supported under the Health Equity Fund (HEF).
Experiences from these free care measures have been incorporated
to better design the FMCI.
Two important lessons learnt are that: (i) the reality of
provided free services has to be rigorously
verified; and (ii) the content of invoices sent by health
facilities for reimbursement also need to
be strictly controlled. These two key lessons have been
incorporated in the design of this AF.
Consistency with the existing Health System Performance
Project
9. The original grant amount for the HSPP was USD 33.8 million
(USD 22.8 million from IDA and USD 11 million from the Multi-Donor
Trust Fund for Health Results Innovation).
It was approved on April 9, 2010 and became effective on
September 30, 2011. The first project
development objective (PDO) is to increase the coverage of
quality maternal and neonatal
health care services in the target districts. This PDO is broken
down into two intermediate
outcomes: (i) improving health facilities performance through
Result-Based Financing (RBF);
and (ii) enhancing financial accessibility to these health
services. The second PDO is to
strengthen the institutional capacity of the Ministry of Health
(MoH). Through this PDO, the
Project will: (i) prepare the implementation of a Sector Wide
Approach (SWAp); and (ii)
improve planning, budgeting and monitoring functions within the
MoH.
10. The HSPP has three components: (i) strengthening
accountability of health facilities through the piloting of an RBF
mechanism (USD 18.0 million); and (ii) increasing financial
accessibility to health services, through improvements of the
HEF (USD 13.8 million). Malaria
care is one of the services targeted by both components. There
is also a third small component on
technical assistance for institutional strengthening (USD 2.0
million). Since the proposed AF will
enhance the impact of Project’s Component 1 on health facilities
performance and Component 2
on financial accessibility, it is fully consistent with the
original Project, not only in terms of
development objectives, but also in terms of design and
geographical scope.
11. The project is currently rated Satisfactory for progress
towards achievement of PDO. Implementation progress had long been
rated Moderately Satisfactory due to delay in
project effectiveness. The delay was due to the fact that the
Bank’s internal approval process for
selection of a consulting firm (which was the last effectiveness
condition to be fulfilled) took
almost five months, because of suspicions of procurement
irregularities, which had to be
investigated (and turned out to be non substantial). This led to
an effectiveness flag, which will
be turned off in May 2013 (according to OP/BP 13.00). To
mitigate risk for further procurement
delays, supervision has been strengthened by adding one more
senior procurement specialist to
the task team. In addition, procurement training for the MoH has
been scheduled for February
2012 to ensure capacity strengthening at government level. Note
also that all audits on the
project are current. Given that effectiveness has been declared
only in September 2011, no audit
is due yet. While the proposed AF satisfies the requirement of
12 months of project
implementation since the Board approval, an approval from the
Regional Vice President (RVP)
has been obtained to proceed with this AF, given that the
project has only been effective since
September 30, 2011.
-
11
12. Since effectiveness (Sept 30, 2011), project implementation
has been on track, as described in the latest Implementation Status
& Results (ISR). Overall safeguard compliance
has been so far rated Satisfactory. The Project has already
committed an amount of $5 millions.
Key tasks for components 1 and 3 are under implementation. A
first disbursement request of
USD 2 million has already been submitted, and a second request
of another USD 2 million is
scheduled for February 2012. The Project is in substantial
compliance with the legal covenants,
with some slight delays in meeting two (2) dated covenants given
the associated delays related to
harmonization efforts with other donors. These two legal
covenants are (i) the purchase of an
accounting software and (ii) the recruitment of a financial
auditor. The approval of the Terms of
Reference (TORs) has been delayed by the fact that it has been
recently agreed (after Board
approval) that both services will be used by 3 partners (Bank,
Global Alliance for Vaccines and
Immunization and Global Fund). The TORs are now finally approved
and the procurement
process is ongoing. Completion of this process is expected by
February 2012.
13. The World Bank (WB) has been actively engaged in malaria
control interventions in Benin, especially through the Malaria
Control Support Project which closed in June 2011. As
part of the Africa Region Malaria Booster Program, the project
aimed to support the
implementation of the Second National Malaria Control Strategy
(2006-2010), measured through
increased access to, and utilization of, an effective package of
malaria control interventions. Data
from the NMCP shows that there has been a steady decline between
2005-2009 on some of the
key indicators including number of reported malaria deaths,
malaria case fatality rates, and
number of simple and severe malaria cases reported by health
facilities. While these rapid
declines are plausibly attributed to all Roll Back Malaria
partners’ support to Benin’s new
malaria policy and protocols, the role of the Bank’s project is
strongly acknowledged by both
NMCP and partners on two fronts: (i) it allowed for a
substantial injection of resources in
supporting the Strategy1; and (ii) it was instrumental in
attracting substantial additional
resources, notably from the USAID/PMI2. The proposed AF will
thus be a way for the WB to
stay engaged in supporting the GoB’s effort to malaria control.
In addition, a follow-on Malaria
Booster operation is currently under development to continue
critical support focusing on Bank’s
comparative advantage, especially in areas of strategic program
management, capacity building
and health systems strengthening.
14. Processing of a new lending operation was considered as an
alternative but dropped for two reasons. First, preparation of a
USD 10 million project would result in high transaction
costs. Secondly, the tight timeline for implementing the FMCI
would not be consistent with the
time requirements associated with preparing a new project.
Another alternative was to restructure
the parent Project, given that it had not disbursed anything so
far. This option was also ruled out
for two reasons. First, the lack of disbursement is explained by
the fact that the parent Project
just recently became effective on Sept 30, 2011 due to delays in
meeting one of the project
effectiveness conditions (as explained in paragraph 11). Since
then, implementation has been on
track. Second, out of the USD 33.8 million designated for the
parent Project, USD 16 million
cannot be reallocated as it includes: (i) USD 11 million from a
Trust Fund dedicated to RBF, and
(ii) USD 5 million committed for the payment of a contract with
a technical assistance firm.
1 The Project constituted about 65% of all available financing
(at the time of project approval),
2 Draft Implementation Completion and Results Report, Malaria
Control Support Project, December 2011
-
12
Consequently, if the project was restructured without AF, only
USD 17.8 million could be
reallocated to fund the FMCI. This would leave a mere USD 7.8
million to implement all the
activities of the parent Project. Obviously, a 56% reduction in
the parent Project’s available
budget would require removing or scaling down most of the
activities, resulting in a significant
risk of poor implementation of the parent Project.
Consistency with Government priorities and Country Assistance
Strategy (CAS)
15. Benin’s new Poverty Reduction Strategy Paper (March 2011)
includes strengthening of human capital as one of the six pillars,
making reference to improving
accessibility and quality of health services and highlighting
the importance of three Millenium
Development Goals (MDGs): under-five mortality rate; maternal
mortality and combating
malaria, HIV/AIDS and tuberculosis3. The 10-year National Health
Sector Development Plan
(PNDS 2009-2018) recognizes malaria as the main cause of child
mortality and adult morbidity
and calls for concerted action to combat this disease as a
priority. The third NSP 2011-2015
builds on the PNDS and supports the same objectives, specifying
the interventions with some
refinements to: (i) extend coverage of target groups from
vulnerable groups to cover the entire
population; and (ii) ensure more routine testing in health
facilities to confirm malaria diagnosis
dispensing ACT.
16. The proposed AF is consistent with the CAS 2009-2012 which
plans to direct Bank support towards increasing “access to basic
services”, and more specifically, towards
“improving health services”. The AF is also consistent with the
Bank’s new Africa strategy:
Pillar 2 of this strategy focuses on implementing mechanisms for
protecting households from
various shocks, including those related to health. The proposed
AF is expected to reduce the
financial and clinical burden of malaria morbidity. In addition,
Benin has already implemented
several user fees exemptions policies in health services, such
as Free C-Section and Free Health
Care for the poorest through the HEF. The original HSPP is
expected to support the HEF,
therefore the proposed AF will increase synergies with the
ongoing Bank’s support to the
country’s free care strategies.
III. PROPOSED CHANGES
17. As the AF intends to fund the FMCI for pregnant women and
children under five, the first PDO will be slightly expanded to
increasing the coverage of quality maternal,
neonatal and child health care services in the targeted
districts. The second PDO will remain
unchanged. In addition, an outcome indicator will be added so as
to follow and monitor the
impact of this FMCI policy. This indicator is the following (for
PDO 1, indicators for coverage
in the targeted districts): Number of beneficiaries of the Free
Malaria Care4.
18. New activities to be added to support the FMCI would be
under Component A and B of the parent project:
3 Malaria specific interventions include: prevention, case
management, behavior change communication,
epidemiological and entomological surveillance and research. 4
Number of beneficiaries (under-five children and pregnant women)
benefiting from free malaria care in the 8
districts. Only cases confirmed by biological tests and
validated by the NMCP are considered.
-
13
Component A: Improvement of health facilities performance
through Result-
Based Financing (additional USD 2.7 million)
Reimbursement of services and operating costs associated with
the four packages of
the FMCI in the eight health districts targeted by the HSSP.
These costs include
medical services and top-ups for health workers. Estimated costs
are USD 2.7
million. Disbursements for this activity follow an output-based
disbursement
mechanism: after going through a verification process, the
health facilities assigned
to RBF and contracted by the MoH will be reimbursed on the basis
of number of
(fee exempted) malaria services they have provided. The AF will
follow the same
mechanism but with four additional indicators added to the
existing RBF design to
ensure provision of services related to FMCI.
Component B: Support to improved financial accessibility
(additional USD 7.3
million)
Procurement of goods included in the four packages of the FMCI
in the eight
health districts targeted by the HSSP, including Artemisinin
Combination Therapy
(ACT), Rapid Diagnostic Tests (RDTs) and treatment kits. Overall
cost is estimated
at USD 6.3 million. Procurement procedures will be launched well
in advance and
will be organized in such way so as to allow for ACT treatment
to take place in
parallel to the rolling out of RDTs, in order to reduce misuse
of ACTs for fever not
attributable to malaria, as well as to avoid inefficiencies and
high costs. Required
quantities have been reflected in the procurement plan.
Communication, information, M&E and training activities (USD
1 million) as
described in the strategic FMCI document including community
mobilization about
the Free Malaria Care, media communication to communities,
information and
communication to local authorities, health district teams and
health workers,
training for health workers on the diagnostic and treatment of
malaria cases.
19. Note that given the changes mentioned above, the HRIG grant
agreement will need to be
amended accordingly given that it is jointly co-financing
Component A of the Project.
20. The proposed additional grant of USD 10 million would bring
the total project
amount to USD 43.8 million. The table below provides the
financing allocation by component
of the original project and the new proposed AF.
Table 1: Revised budget allocation by components
Component Original Cost
(USD million)
Additional cost
(USD million)
Total revised
cost
(USD million)
-
14
A:
Improvement
of health
facilities
performance
through RBF
A.1. Financing of RBF
credits (including malaria
services)
12 2.7 14.7
A.2. Support to RBF
implementation and
supervision
6 -- 6
B: Support to
improved
financial
accessibility
B.1. Strengthening of
processes to identify the
poorest households
10.3 -- 10.3
B.2. Support to the
Health Equity Fund
2.5 -- 2.5
B.3. Support for
preparation of a proposal
for a Universal Health
Insurance Scheme
1 -- 1
B.4. Procurement of
medical goods included
in the four packages of
the FMCI in the eight
health districts targeted
by the HSPP
0 6.3 6.3
B.5. Communication,
information, M&E and
training activities for
implementing the FMCI
0 1 1
C: Technical assistance for institutional
strengthening
2 -- 2
Total 33.8 10 43.8
21. Overall implementation arrangements will remain unchanged
from the original project, with the MoH assuming the primary role
for project implementation, including oversight,
coordination and fiduciary management, through a Project
Coordination Unit (PCU) placed
under the General Secretary of the Ministry (GSM). As the AF
will focus on supporting the
GoB’s FMCI, responsibilities of the different entities to
implement this initiative will be as
follows (see also Annex 4 for illustration of the implementation
arrangement).
The PCU will:
-
15
- reimburse health facilities for goods related to the four
malaria services, once the PCU has received invoices from these
health facilities and once
these invoices have been controlled by the NMCP and the third
party
controller;
- contract with suppliers of goods related to malaria (drugs,
kits and RDTs), according to the WB procurement guidelines;
The NMCP will: - support the PCU to prepare tenders for
malaria-related goods; - control the technical adequacy of invoices
submitted by health facilities;
The CAME (Central Drugs Procurement Unit) will: - store and
distribute the malaria-related procurable items to health
facilities;
The health facilities will: - report their production in terms
of free malaria services and will submit the
corresponding invoices (for non-procurable items) to the
PCU;
- receive two types of additional resources related to the free
malaria care initiative: (i) additional goods (from CAME) and (ii)
additional funding for
non-goods items (from the PCU).
A third party controller firm (already in place) will: - control
the reality of services to be reimbursed (i.e. ensuring that
services to
be reimbursed have been actually produced and provided to the
eligible
groups).
22. In addition, a steering committee will continue to monitor
project activities. This committee, chaired by the Minister of
Health and including the Ministries in charge of Finance,
Civil Services and Development, will continue to function as an
oversight role of the project. In
particular, it will continue to approve annual work plans,
national RBF framework and other
strategic documents.
Overall fiduciary arrangements
23. The proposed AF will include two main types of expenditures.
A first type consists of medical goods, including drugs (mostly
ACTs), RDTs and kits for malaria treatments. The
estimated amount for these goods is USD 6.3 million (about 70%
of the unit cost of the four
services). These goods will be procured by the PCU, in
collaboration with NMCP and CAME.
24. A second type of expenditures is the services and operating
costs of the 4 services. They include services and top-ups for
civil servants. The estimated amount is USD 2.7 million (30%
of the unit cost of the 4 services). These items will be funded
through the Output-Based
Disbursement (OBD) mechanism already in place with the parent
Project5. That will require a
rigorous evaluation of the unit costs.
25. Overall, to cover the costs faced by health facilities
because of the removal of user fees on malaria care, these
facilities will receive two distinct types of support: (i) an
in-kind support,
consisting in goods (drugs, RDTs…) distributed free of charge by
the CAME to the health
5 In the parent project, the categories A.1 and B.2 are funded
through OBD. The Additional Financing also
introduces A.3, for malaria services.
-
16
facilities, and (ii) a monetary support, consisting of services
and operating costs (services, top-
ups…) funded through an OBD mechanism. This combination ensures
both (i) a high efficiency
for procurable expenditures (70% of the unit costs) and (ii) a
strong accountability of health
facilities (through the OBD mechanism).
26. Both mechanisms (standard procurement and OBD) are already
in place within the parent Project.
27. Finally, an amount of USD 1.0 million is allocated to
strengthen communication and M&E related to free malaria care.
This support will consist in training, workshops, consulting
services and operating costs.
Financial management arrangements
28. To implement this proposed AF, no changes in financial
management arrangements and requirements are necessary. As for the
parent project, the PCU-HSPP will be in charge of the
financial management of the AF including the preparation of
technical and financial reports. It
will also monitor the disbursements of the funds and will ensure
that they are in compliance with
IDA requirements. The PCU-HSPP has already been strengthened by
key staffs including
Financial and Procurement Specialists.
29. The table below summarizes the fiduciary arrangements for
this AF:
Table 2: Cost allocation by activity
Activities Eligible expenditures Cost
Funding of malaria care
services at facility level
Procurable items:
Drugs (mostly CTAs), RDTs
and kits for malaria treatments
$6.3 million (70% of the
unit cost of the malaria care
services)
Non-procurable items:
services and top-ups for civil
servants
$2.7 million (30% of the
unit cost of the malaria care
services)
Communication and
M&E strengthening at
central and district level
Training, workshops and
consulting services and
operating costs
$1.0 million
30. Disbursements. In order to promote a single project
approach, the AF will use the existing designated account at the
BCEAO (Banque Centrale des Etats de l’Afrique de l’Ouest).
The ceiling of the Designated Account has been set to CFAF 1
billion. The proceeds of the AF
grant have been allocated to the RBF component under a specific
category (category 4), given
-
17
that these proceeds will fund only malaria care services. All
disbursements for the Project will be
based on monthly Statement Of Expenditures (SOE). In addition,
disbursements for results based
financing component (under categories (1) for the Original
Financing and (4) for AF of the
disbursement table) will be supported with a certified SOE (in
the form attached to the
Disbursement Letter) signed by the independent verification
agent in accordance with terms of
reference acceptable to IDA and consistent with external
controls provisions set out in the legal
agreement (cf. Section I.E of the Amended and Restated Financing
Agreement).
31. The expenditures related to the malaria-related
“non-procurable items” (see table above) will be funded through the
existing Output-Based Disbursement (OBD) arrangement.
Practically, four services/packages will be added to the
existing list of outputs. The arrangements
for OBD are the same as for the parent Project. As mentioned in
the PAD of the parent Project,
all disbursements from the Grant accounts regarding the RBF
component (A.1 and A.3) will be
certified SOE (as stated above). This auditor (already selected)
has set up a full-time “district
controller” in each of the 8 districts. These controllers verify
the reality of outputs, in checking
consistency between reported outputs and facilities registers.
In addition, the operational auditor
is currently selecting Community Based Organizations (CBOs) to
conduct community checks.
The detailed arrangements for controlling output are presented
in the annex 5 of this Project
paper. Under the RBF component, subsidiaries’ accounts in an
acceptable commercial bank will
be opened by eligible health centers. To avoid misuses of RBF
credits, the Finance specialist at
each district level will provide ex-ante clearance for all
expenditures to be made by the health
center.
Table 3: Revised Disbursement Table - Original and Additional
Financing Category Amount of the Original
Grant Allocated (USD)
Amount of
the
Additional
Grant
Allocated
(USD)
Percentage of
Expenditures to be
Financed
(inclusive of Taxes)
IDA TF IDA IDA TF
(1) Goods and services to
be financed from the proceeds of
Maternal, Neonatal and Child
Health Services Grants under
Parts A.1(i) and A.1(ii) of the
Project
1,000,000 11,000,000
8.33% 91.67%
(2) Goods and services to
be financed from the proceeds of
HEF Health Services Grants
under Part B.2 of the Project 2,500,000 0 0 100.00%
(3) Goods, consultants’
services, Training, and Operating
Costs for Parts A.2, B.1, B.3, B.4
and B.5 and C of the Project 19,300,000 0 7,300,000 100.00%
-
18
(4) Goods and services to
be financed from the proceeds of
Maternal, Neonatal and Child
Health Services Grants under
Part A.1(iii) of the Project
0 0 2,700,000 100% 0
TOTAL AMOUNT 22,800,000 11,000,000 10,000,000
AF Estimated Disbursements (Bank FY/US$m)
FY 12 13 14 15 16
Annual 1.0 5.0 4.0 0 0
Cumulative 1.0 6.0 10.0 10.0 10.0
Procurement arrangements
32. All goods and services will be procured according to the
provision of Annex 8 (Procurement Arrangements) of the parent
project Appraisal Document. The only changes to the
existing procurement arrangements in the parent Project are
that:
Procurement would be carried out in accordance with the World
Bank’s “Guidelines: Procurement under IBRD Loans and IDA Credits”
dated January
2011; “Guidelines: Selection and Employment of Consultants by
World Bank
Borrowers” dated January 2011; as well as "Guidelines on
Preventing and
Combating Fraud and Corruption in Projects Financed by IBRD
Loans and IDA
Credits and Grants”, dated October 15, 2006 revised in January
2011.
The drugs and other procurable medical items will be procured in
collaboration with the NMCP and with CAME who will ensure the
storage and distribution..
33. The summary of procurement plan is provided in Annex 4 of
the present document.
Closing date
34. The project closing date is extended by a year, from
December 31, 2014 to December 31, 2015. This extension is justified
by the delay in effectiveness (one year) of the parent Project.
The extension will restore the initial duration for the Project
(4 years).
Other legal changes
35. As mentioned in paragraph 12, after Board approval of the
parent project, harmonization efforts have been made with two other
partners (GAVI and Global Fund). As a consequence, it
has been agreed that the three partners will use the same
accounting software and will be audited
by the same auditor. This harmonization has led to some delays
in purchasing the accounting
software and selecting the auditor. Consequently, it is proposed
that these actions will have to be
completed no later than two months after effectiveness of this
Additional Financing.
-
19
Monitoring and Evaluation (M&E)
36. Under the RBF component of the original Project, an
independent “district controller” is assigned in each of the eight
health districts to support the district health team to
measure,
control and verify the RBF results reported by the health
facilities. It is proposed that the scope
of work of these “district controllers” be extended to also
include the control of the malaria care
services supported by the AF. These “district controllers” would
also be part of the quality
control missions for the FMCI led by the NMCP. In addition, the
same mechanisms used for
RBF would be used for the proposed AF, such as consistency check
between registers and
reported information, as well as contracting of Community Based
Organizations (CBO) to
conduct patient satisfaction surveys in order to measure the
qualitative aspects of care. Annex 5
provides a detailed description of these control
arrangements.
37. A baseline household survey was already conducted in the
eight districts as part of the Impact Evaluation of the RBF
component under the original project. This survey included
questions related to health service utilization. In order to
rigorously measure the impact of FMCI
in the eight target districts, follow-up surveys foreseen under
the original project will include
additional questions linked to the new Policy.
IV. APPRAISAL SUMMARY
Economic and financial analyses
38. The expanded activities funded through the Additional
Financing do not lead to any significant difference in the results
of the economic analysis from the original one. Indeed, these
additional activities will improve the cost-effectiveness of the
existing Project. Increasing access
to malaria care by removing the financial barriers for
vulnerable groups would allow early
diagnosis and prompt treatments which prevent from
complications, more severe morbidity and
mortality. And there is a huge potential for such improvements.
For instance, only 10% of under-
five children are treated with an ACT (ACTWatch survey, 2009).
Moreover, the odds of
receiving ACT and diagnostic testing is 2.68 for children from
the wealthiest quintile in
comparison with those from the lowest one6. It is consequently
expected that the Malaria Free
Care will reduce inequities in malaria care access.
39. Malaria health burden is heavy in Benin. According to a
survey conducted in November 2011 by the National Malaria Control
Program, parasitological malaria prevalence is 41% for
under-five children and 33% for pregnant women. For Sub-Saharan
Africa, it is estimated that,
malaria-associated anemia is responsible for 3.7% of maternal
mortality7. Indeed, malaria can
induce under-nutrition, low birth weight, increased
susceptibility to general infection. For
6 Littrell et al, Monitoring fever treatment behaviour and
equitable access to effective medicines in the context of
initiatives to improve ACT access: baseline results and
implications for programming in six African countries,
Malaria Journal , October 2011. 7 Breman, Mills, Snow and al.,
Disease control priorities in developing countries, April 2006.
-
20
children, severe malaria could lead to some major relapses
including cognitive impairment,
behavioral disturbance and blindness.
40. Thus, additional activities linked to free malaria care
would increase the impact of the Project on the reduction of
maternal and child mortality. The impact of the free care will
be complementary with the national prevention strategy for the
two vulnerable groups (for
instance, the national bednets campaign in 2011 for under-five
children, where 1.7 millions
bednets were distributed) and synergic with services subsidized
through RBF in the 8 targeted
districts (for instance, Intermittent preventive treatment (IPT)
during pregnancy and bednets for
pregnant women).
41. Case management with ACT has proven to be a cost effective
intervention in West Africa with an average cost effectiveness of
9$ per Disability-Adjusted Life year (DALY)
averted (with 80% coverage)8. Estimates by NMCP of number of
cases are consistent with the
malaria situation and the important efforts made on prevention
in Benin: one case per under-five
children per year and 40% of pregnant women having malaria.
These numbers would be adjusted
during implementation of the Initiative and considering the
expected improvements in malaria
diagnostic and case management. The cost of the Free Malaria
Care funded by the Additional
Financing is small: around 2.3$ per capita or 9.9$ per
vulnerable targeted person in the eight
districts.
Technical and sustainability analysis
42. The proposed AF would support the GoB’s effort to enhance
financial accessibility for malaria care to vulnerable groups
through their newly launched FMCI. The initiative aims at
removing user fees for simple and severe malaria interventions
for pregnant women and children
under five years of age through four packages that include
diagnostics, treatment, exams and
visits/hospitalization at health facility levels in their
communities. The contents of the package,
conditions of eligibility, modalities of execution and
monitoring are determined by the National
Strategy for FMCI which was developed by the NMCP and adopted by
the GoB and partners in
August 20119.
43. This strategy suffers from a lack of funding. As estimated
by the NMCP and confirmed during appraisal, the annual cost of FMCI
is at least 9 billion CFA francs ($ 19 million). The
Government has allocated a billion FCFA ($ 2 million) in its
2012 budget, while USAID has
committed funding of 2.5 billion CFA francs ($ 5 million) per
year for 4 years. Without support
by the WB, the annual gap is 5.5 billion FCFA ($ 12
million).
44. The main discussion during appraisal focused on the scope of
activities of FMCI to be financed by additional funding. An initial
proposal was to fund the overall FMCI, that is to say
mainly to finance inputs, as does USAID. The World Bank has
expressed strong reservations on
this proposal, for two reasons. First, it must be remembered
that a policy of free care does not
merely consist in providing free inputs. A free care policy is
about reimbursing services to health
8 Morel, Lauer and al., Cost effectiveness analysis of
strategies to combat malaria in developing countries, 2005.
9 Stratégies de la mise en œuvre de la gratuité de la prise en
charge des cas de paludisme chez les femmes enceintes
et les enfants de moins de 5 ans, August 2011
-
21
facilities. This assumes (i) a mechanism for reimbursement that
is fast and reliable, and (ii) a
mechanism to control the reality and quality of the provided
services. None of these mechanisms
is now in place in Benin, except in the eight health areas
already supported by the HSPP. Second,
by allocating the entire additional funding to inputs, Bank
funding would be exhausted after
about 6 months, inevitably triggering questions about the
sustainability of FMCI. Such a
sustainability issue cannot be resolved in 6 months.
45. For these two reasons, a second proposal made by the World
Bank and accepted by the Government is to limit the scope of
additional funding to the eight health districts of the HSPP.
Funding will then cover the needs of these eight areas for 2
years. This arrangement meets the
fiduciary requirements of the World Bank, while leaving
sufficient time to prepare for the
sustainability and nationwide implementation of FMCI. To do
this, it was agreed that the
implementation of additional funding in year 2 will be
conditioned by the production by the
Government of a report identifying domestic and external
resources to sustain the FMCI. This
condition will ensure that, as soon as the end of the first year
of implementation, the Government
will have defined a strategy to fund the whole program
(including the small amounts for civil
servants’ incentives) with only domestic resources10
. This condition is consistent with the
arrangement made in the parent Project (para 78), where in year
3 of implementation, the
Government will start to redirect existing funds to the benefit
of the RBF program (also funding
incentives for civil servants).
46. Also, in order to enhance efficacy of intervention, the
proposed AF will take a two-pronged approach: (i) provision of
medical procurable goods, including drugs (mostly ACTs),
RDTs and kits for malaria treatments which will be procured by
the PCU following the same
arrangements used in the recently closed Malaria Booster Control
Program; and (ii) payment to
health facilities through an Output-Based Disbursement (OBD)
mechanism already in place
under the parent Project whose design of RBF has incorporated
lessons from other countries’
successful RBF projects and adapted to the Benin
environment.
47. As usual in programs where providers are paid on the basis
of the production they report, there is a high risk that these
providers will artificially inflate their reported production. This
risk
exist for the FMCI supported by the AF. It is however fully
addressed by the strong control
arrangements that are in place with the parent Project (see para
36 for details).
48. Another risk with the proposed approach (i.e. supporting
only 8 districts) is that people from other districts may travel to
the Bank 8 districts to receive free care. The Team believes
this
risk is rather limited, for the following reason. Available data
show that people are ready to
travel far away only for major health services, such as surgery,
delivery or c-section. To seek
basic health services (such as malaria diagnosis and treatment),
people will usually not travel
10
It is worth mentioning here that there is currently an untapped
and important financial resource in health facilities.
Since last year, the Government has indeed decided to hire as
civil servants (paid by the Government) all contract-
based staff (previously paid by health facilities out of user
fees). This major shift in financing has led to a situation
where many health facilities have now a significant surplus of
financial resources, which could be used for funding
the FMCI. The Government has agreed to assess the extent of this
surplus and to use it - in the above mentioned
study - as a way to mobilize national resources for the
FMCI.
-
22
farther than 5-10kms. In other words, this “spill-over effect”
will be limited to the villages in the
immediate neighborhood of the 8 districts.
49. Implementing a free care strategy could end up in “crowding
out” resources at the expense of prevention, which remain a highly
cost-effective intervention. On the basis of the
existing national strategy against malaria and its funding
structure, there is no evidence that such
a crowding out can occur. The national strategy still puts
prevention as its very first priority (see
pillar 1.1 in the strategy). In addition, most of the funding
for preventive interventions
(especially the distribution of bed nets) till 2014 comes from
the Global Fund. As mentioned
before, this funding cannot be redirected to FMCI, as this is a
new activity. This lack of funding
flexibility (or lack of “crowding out”) is actually one of the
reasons why the Bank is proposing
this AF, given that the Global Fund cannot fund it now.
Fiduciary
50. The AF procurement activities will be implemented by the
existing PCU, under the existing arrangements of the parent
project. Procurements processes for drugs, kits and RDTs,
will be carried out by the PCU with technical support from the
NMCP and CAME. Note that the
PCU includes a recruited procurement specialist, who happened to
be the former procurement
specialist of the Malaria Booster Control program.
51. As for financial management, the proposed AF will not
include any new arrangement. The existing ones are acceptable for
the Bank.
Social and environmental
52. The underlying technical appraisal of the original project
remains valid. As explained in the original PAD, the project is
expected to have a positive social impact by: (i) improving
accessibility of health care for the poorest households,
especially targeting the most vulnerable
groups of the population; (ii) enhancing community ownership as
for monitoring the quality of
basic health services; and (iii) the preparation process of the
Benin Health System Performance
Project remains highly participatory with extensive work and
consultation among the key
stakeholders, especially on decentralized levels in project
target districts.
53. As with the parent Project, the provision of malaria care
services might entail an increased production of medical waste,
especially in relation to planned procurement of goods
such as ACTs, RDTs and lab reagents. Consequently, the proposed
project has been classified as
Category B for environmental screening purposes given the risks
associated with the handling
and disposal of medical and general health waste. This project
is not expected to generate any
major adverse environmental impact.
54. The proposed Additional Financing does not introduce new
activities that will trigger additional safeguards policies to the
original project; but enhances the impacts of component 2
on financial accessibility, thus, making it fully consistent
with original project, not only in terms
of development objectives, but also with respect to design and
geographic coverage. The
implementation of the prepared safeguards instrument of the
parent project: the Medical Waste
-
23
Management Plan (MWMP) has been satisfactory; there has been
training to health care
providers and health care personnel on medical waste management
procedures and practices.
Further, some MWMP equipment such as waste bins, handgloves and
needle cutters have been
purchased and are in the process of being distributed to the
regional and local health centers.
55. The overall implementation risk is rated as moderate. The
main risk is the weak financial sustainability of the program. This
risk is mitigated by the dated covenant requiring the
Government to produce (by the end of the first year of
implementation) a strategy for mobilizing
additional resources and therefore for being able to fund the
program without Bank support.
-
24
Annex 1:
BENIN: Health System Performance Project
Revised Results Framework
Revisions to the Results Framework Comments/ Rationale for
Change
PDO
Current (PAD) Proposed The first PDO would consist in
increasing the coverage of quality
maternal and neonatal health care
services in the target districts. The
PDO would be broken down in
two intermediate outcomes: (i)
improving health facilities
performance through Result-
Based Financing (RBF); and (ii)
enhancing financial accessibility
to these health services. The second PDO is to strengthen
the institutional capacity of the
Ministry of Health.
The first PDO would consist in
increasing the coverage of quality
maternal, neonatal and child health
care services in the target districts.
The PDO would be broken down
in two intermediate outcomes: (i)
improving health facilities
performance through Result-Based
Financing (RBF); and (ii)
enhancing financial accessibility
to these health services. The second PDO is to strengthen
the institutional capacity of the
Ministry of Health.
The financing of the Free
Malaria Care for under-five
children is expected to impact
highly the coverage and the
quality of these services for
the children, who come
mainly to health centers due
to malaria.
PDO indicators
Current (PAD) Proposed change*
1. Increasing
coverage of
quality
maternal,
neonatal and
child health
care services
1. Rate of pregnant
women that had at least 4
antenatal care visits
before delivery
Continued
2. Rate of poorest
pregnant women that had
at least 4 antenatal care
visits before delivery
Continued
3. Rate of assisted
deliveries among all
pregnant women
Continued
4. Rate of assisted
deliveries among the
poorest pregnant women
Continued
5. Number of pregnant
women receiving
antenatal care during a
visit to a health provider
(IDA 15 Core Indicator)
Continued
6. Rate of antenatal care
visits (among all
pregnant women)
Continued
-
25
Revisions to the Results Framework Comments/ Rationale for
Change
complying with quality
standards 7. Rate of deliveries
adequately referred by
primary care level
facilities
Continued
8. Number of children
immunized (IDA 15
Core Indicator)
Continued
9. Number of
beneficiaries11
of the
Free Malaria Care
New The Additional Financing will fund the Free Malaria Care
for pregnant women and
under five children in 8
districts. 10. Direct beneficiaries
(with % of women) (IDA
15 CORE)
Change in the end of
the project target
value
The project target value will
increase as more pregnant
women and under-five
children will benefit from the
Project, notably through the
funding of the Free Malaria
Care in the 8 targeted
districts. 2.Strenghtening
institutional
capacities of
the Ministry of
Health (MoH)
Share of MoH budget
allocated to health
districts
Continued
Concentration index of
budget allocation to
health district across
population densities
Continued
Intermediate Results indicators
Current (PAD) Proposed change*
Component 1 –
Improvement
of health
facilities
performance
through Result-
Based
Financing
(RBF)
1. Competency score of
health workers in
maternal and neonatal
health
Continued
2. Health personnel
receiving training (IDA
15 CORE)
Continued
3. Average availability of
essential drugs in health
facilities
Continued
4. Average availability of Continued
11
Beneficiaries of the Free Malaria Care are defined as under-five
children and pregnant women who benefit for
free of one of the four packages of care of the policy and whose
cases are confirmed through RTD or microscopy. It
means that only cases validated by district controllers, EEZS
and the NMCP would be considered as Beneficiaries of
the Free Malaria Care.
-
26
Revisions to the Results Framework Comments/ Rationale for
Change
essential equipment in
health facilities 5. Average availability of
health workers (i.e. “one minus
absenteeism rate”)
Continued
6. Motivation of health
workers (Likert scale,
spanning from 1 to 5)
Continued
7. % of facilities that
received RBF credits
each year
Continued
8. % of facilities whose
RBF results have been
fully verified each year
Continued
Component 2 –
Support to
Improved
Financial
Accessibility
1. Average cost of key
maternal health services
for patients (including
informal payments)12
Continued
2. Index of benefit of
maternal health services
as perceived by women
(on a Likert scale,
spanning from 1 to 5)
Continued
3. Number of poor
households identified Continued
4. % of identified poor
households enrolled in
the e-health card
program
Continued
5. % of identified poor
households being
exempted from fees
thanks to their e-health
card
Continued
6. Percentage of under
five children receiving
Free Malaria Care
Services
New The Additional Financing will fund the 2 packages of
Free
Malaria Care for under-five
children in the 8 targeted
districts. 7. Percentage of
pregnant women
receiving Free Malaria
Care Services
New The Additional Financing will fund the 2 packages of
Free
Malaria Care for pregnant
women in the 8 targeted
districts.
12
This amount is equal to the average of the amount of costs for
(i) one antenatal care visit, (ii) one uncomplicated
delivery and (iii) one complicated delivery.
-
27
Revisions to the Results Framework Comments/ Rationale for
Change
Component 3 –
Technical
Assistance for
Institutional
Strengthening
1. Number of SWAp
“building blocks” in
place (see table 2 for
details)
Continued
2. Strategic 3-year plans
developed according to
defined principled
Continued
3. New formulas for
allocation of the budget
to districts are utilized
Continued
4. M&E system with no
overlapping processes Continued
* Indicate if the indicator is Dropped, Continued, New, Revised,
or if there is a change in
the end of project target value
-
28
Annex 1: Revised Project Results Framework
Project Development Objective (PDO):
The first PDO would consist in increasing the coverage of
quality maternal, neonatal and child health care services in the
target districts. The PDO would be broken down in two
intermediate outcomes: (i) improving health facilities
performance through Result-Based Financing (RBF); and (ii)
enhancing financial accessibility to these health services.
The second PDO is to strengthen the institutional capacity of
the Ministry of Health.
PDO Level Results
Indicators13
Co
re
UOM14
Baseline
Original
Project
Start
(2010)
Progres
s To
Date
(2012)15
Cumulative Target Values16
Frequency Data Source/
Methodology
Responsibility
for Data
Collection
Comments 2012 2013 2014 2015
1. Rate of pregnant women
that had at least 4 antenatal
care visits before delivery
% 61% 61% 65% 70% 75% 81% - Every 3
months
- Facilities
records
- Control of
facility
records for a
random
sample of
women
- Health
district teams
- M&E third
party17
2. Rate of poorest pregnant
women that had at least 4
antenatal care visits before
delivery
% 51% 51% 56% 62% 68% 75% - Every 3
months
- Facilities
records
- Control of
facility
records for a
random
sample of
women
- M&E third
party
- M&E third
party
13
Please indicate whether the indicator is a Core Sector Indicator
(for additional guidance – please see http://coreindicators).
14
UOM = Unit of Measurement. 15
For new indicators introduced as part of the additional
financing, the progress to date column is used to reflect the
baseline value. 16
Target values should be entered for the years data will be
available, not necessarily annually. Target values should normally
be cumulative. If targets refer to
annual values, please indicate this in the indicator name and in
the “Comments” column. 17
As explained earlier, there are two third parties involved in
data collection and verification. One is the M&E third party,
which is an international firm with
permanent presence in every RBF district. The other one is the
IE (for Impact Evaluation) third party, which is an independent
entity carrying out data collection
annually.
http://coreindicators/
-
29
- Annually - Household
survey
- IE third party
3. Rate of assisted
deliveries among all
pregnant women
% 78% 78% 80% 83% 85% 88% - Every 3
months
- Facilities
records
- Control of
facility
records for a
random
sample of
women
- Health
district teams
- M&E third
party
4. Rate of assisted
deliveries among the
poorest pregnant women
% 56% 56% 61% 67% 73% 80% - Every 3
months
- Facilities
records
- Control of
facility
records for a
random
sample of
women
- M&E third
party
- M&E third
party
- Annually - Household
survey
- IE third party
5. Number of pregnant
women receiving antenatal
care during a visit to a
health provider (IDA 15
Core Indicator)
Number
220,000 220,000 235,000 250,000 265,000 280,000 - Every 3
months
- Facilities
records
- M&E third
party Annual
visits - Annually - Household
survey
- IE third party
6. Rate of antenatal care
visits (among all pregnant
women) complying with
quality standards
% 39% 39% 45% 50% 60% 70% - Every 3
months
- Facilities
records
- Health
district teams
- Exiting
patients
surveys
- M&E third
party
7. Rate of deliveries
adequately referred by
primary care level facilities
% 10% 10% 12% 15% 20% 25% - Every 3
months
- Facilities
records
- Health
district teams
- Exiting
patients
surveys
- M&E third
party
- Analysis of
medical
records in
- M&E third
party
-
30
referral
facilities
8. Number of children
immunized (IDA 15 Core
Indicator)
Number
70,000 70,000 75,000 80,000 90,000 100,000 - Every 3
months
- Facilities
records
- M&E third
party
- Annually - Household
survey
- IE third party
9. Number of beneficiaries
of the Free Malaria Care
Number
0 0 0 150,000 320,000 415,000 - Every 3
months
- Facilities
records and
bills sent to
PNLP
- Health
district teams
with district
controllers
Number of
beneficiaries
(under-five
children and
pregnant
women)
benefiting
for free of
malaria care
in the 8
districts.
Only cases
confirmed
by
biological
tests and
validated by
the NMCP
are
considered.
- Annually - Household
survey
- IE third party
Share of MoH budget
allocated to health districts % 39% 39% 40% 45% 55% 65% -
Annually - Annual
budget
- Ministry of
Health
Concentration index of
budget allocation to health
district across population
densities
0.22 0.22 0.18 0.15 0.12 0.10 - Annually - Annual
budget
- Ministry of
Health
Beneficiaries18
Project beneficiaries,
Number
0 0 340,000
510,000
710,000
840,000
- Every 3
months
- Project
records
- Ministry of
Health
Addition of
under-five
children
18
All projects are encouraged to identify and measure the number
of project beneficiaries. The adoption and reporting on this
indicator is required for
investment projects which have an approval date of July 1, 2009
or later (for additional guidance – please see
http://coreindicators).
http://coreindicators/
-
31
Of which female
(beneficiaries)
Number
(60%) (60%) (60%) (45%) (35%) (32%) - Every 3
months
- Project
records
- Ministry of
Health
benefiting of
FMCI in the
8 districts,
which
highly
increases the
number of
project
beneficiaries
but
decreases
the share of
female
beneficiaries
.
-
32
Intermediate Results and Indicators
Intermediate Results Indicators
Co
re Unit of
Measure
ment
Baseline
Original
Project
Start
(2010)
Progress
To Date
(2012)
Target Values
Frequency Data Source/
Methodology
Responsibility
for Data
Collection
Comments 2012 2013 2014 2015
Component 1: Improvement of health facilities performance
through Result-Based Financing (RBF)
Intermediate Result 1: Improved skills and knowledge of
qualified staff
1. Competency score of health
workers in maternal and
neonatal health (see table 2 for
details)
%
52% 52% 58% 65% 72% 80% - Every 3
months
- Knowledge
test
- M& E third
party
2. Health personnel receiving
training (number) (IDA 15
CORE Indicator)
Number
0 0 650 700 800 1,000 - Every 3
months
- Project
records
- Ministry of
Health
Intermediate Result 2: Increased availability of essential drugs
and equipment
3. Average availability of
essential drugs in health
facilities
%
56% 56% 60% 70% 80% 85% - Every 3
months
- Observation
in facilities
- M& E third
party
4. Average availability of
essential equipment in health
facilities
%
66% 66% 70% 73% 76% 80% - Every 3
months
- Observation
in facilities
- M& E third
party
Intermediate Result 3: Increased motivation and availability of
qualified staff
5. Average availability of health
workers (i.e. “one minus
absenteeism rate”)
%
60% 60% 70% 80% 85% 90% - Every 3
months
-
Unannounced
visits
- M& E third
party
6. Motivation of health workers
(see table 2 for details)
Number
between
1-5
2 2 2.5 3 3.5 4 - Annually - Health
workers
survey
- IE third party
-
33
Intermediate Results and Indicators
Intermediate Results Indicators
Co
re Unit of
Measure
ment
Baseline
Original
Project
Start
(2010)
Progress
To Date
(2012)
Target Values
Frequency Data Source/
Methodology
Responsibility
for Data
Collection
Comments 2012 2013 2014 2015
Intermediate Result 4: Effective implementation and monitoring
of the RBF
7. % of facilities that received
RBF credits each year %
0% 0% 100% 100% 100% 100% - Annually - Project
records
- Ministry of
Health
8. % of facilities whose RBF
results have been fully verified
each year
%
0% 0% 80% 100% 100% 100% - Annually - Project
records
- Ministry of
Health
Intermediate Result 5: Component 2 – Support to Improved
Financial Accessibility
9. Average total cost of key
maternal health services for
patients (formal and informal
payments)
Amount
in $
$16 $16 $15 $14 $12 $10 - Every 3
months
- Exit surveys - M& E third
party
10. Index of benefit of maternal
health services as perceived by
women (see table 2 for details)
Number
between
1-5
2 2 2.5 3 3.5 4 - Annually - Household
survey
- IE third party
11. Number of poor households
identified (see table 2 for details) Number
0 0 50,000 100,000 110,000 110,000 - Every 6
months
- Annually
- MoH records
- Control
through a
targeted
household
survey
- Ministry of
Health
12. % of identified poor
households enrolled in the e-
health card program
%
0% 0% 20% 60% 100% 100% - Every 6
months
- MoH records
- Ministry of
Health
13. % of identified poor
households being exempted from
fees thanks to their e-health card
%
0% 0% 10% 30% 60% 90% - Every 6
months
- MoH records
and facilities
records
- Ministry of
Health
14. Percentage of under five
children receiving Free Malaria %
0% 0% 0% 40% 80% 100% - Every 3
months
- Facilities
records and
- Health
district teams
PNLP
estimates
-
34
Intermediate Results and Indicators
Intermediate Results Indicators
Co
re Unit of
Measure
ment
Baseline
Original
Project
Start
(2010)
Progress
To Date
(2012)
Target Values
Frequency Data Source/
Methodology
Responsibility
for Data
Collection
Comments 2012 2013 2014 2015
Care Services bills sent to
PNLP
with district
controllers
that in
average
there is one
malaria
episode per
children
per year.
Numbers
are only for
the 8
selected
districts.
- Annually - Household
survey
- IE third party
15. Percentage of pregnant
women receiving Free Malaria
Care Services
%
0% 0% 0% 10% 30% 40% - Every 3
months
- Facilities
records and
bills sent to
PNLP
- Health
district teams
with district
controllers
PNLP
estimates
that 40% of
pregnant
women
have
malaria per
year.
Numbers
are only for
the 8
selected
districts.
- Annually - Household
survey
- IE third party
Component 3: Strengthening Institutional Capacity of the
Ministry of Health
Intermediate Result 6: Preparing the implementation of a
SWAp
-
35
Intermediate Results and Indicators
Intermediate Results Indicators
Co
re Unit of
Measure
ment
Baseline
Original
Project
Start
(2010)
Progress
To Date
(2012)
Target Values
Frequency Data Source/
Methodology
Responsibility
for Data
Collection
Comments 2012 2013 2014 2015
16. Number of SWAp “building
blocks” in place19
Number
between
0-8
1 1 3 5 7 8 - Annually - Documents
review
- Ministry of
Health
Intermediate Result 7: Improved planning, budgeting and
monitoring
17. Strategic 3-year plans
developed according to defined
principled (yes/no)
Yes/no
No No No No Yes Yes - Annually - Documents
review
- Ministry of
Health
18. New formulas for allocation
of the budget to districts are
utilized (yes/no)
Yes/no
No No No Yes Yes Yes - Annually - Documents
review
- Ministry of
Health
19M&E system with no
overlapping processes (yes/no) Yes/no
No No No Yes Yes Yes - Annually - Documents
review
- Ministry of
Health
19
About eight (8) SWAp “building blocks” are usually identified.
They are the following: (i) a comprehensive plan, (ii) an
evidence-based plan, (iii) a
decentralized planning process , (iv) a strong link between
planning and budgeting, (v) a comprehensive budget, (vi) an MTEF,
(vii) a common M&E system
among donors and MoH and (viii) an MoU between donors and
MoH.
-
36
Annex 2: Operational Risk Assessment Framework (ORAF)
Benin: Health System Performance Project (HSPP) & additional
financing
Stage: Appraisal
1. Project Stakeholder Risks Rating Moderate
Description:
Regarding the AF, the only foreseeable stakeholder risk come
from health facilities and health workers. Currently, these
facilities sell malaria drugs and use the profit from these
drug
sales for paying extra staff and some (small) staff
incentives.
Depending on the level of reimbursement, the Free Malaria
Care Initiative (FMCI) may remove these profits.
Risk Management: During appraisal, unit costs of packages have
been reviewed to ensure they
adequately cover all expenditures currently faced by health
facilities.
Resp: Bank Stage: Appraisal Due Date : before
negotiations Status: Completed
Description:
Another risk with the proposed approach (i.e. supporting
only
8 districts) is that people from other districts may travel
in
the Bank 8 districts to receive free care. The Team believes
this risk is rather limited, for the following reason.
Available
data show that people are ready to travel far away only for
major health services, such as surgery, delivery or
c-section.
To seek basic health services (such as malaria diagnosis and
treatment), people will usually not travel farther than
5-10kms.
In other words, this “spill-over effect” will be limited to
the
villages in the immediate neighborhood of the 8 districts.
Risk Management: Based on data collected during appraisal, the
Team believes the impact of thus risk
is rather limited, for the following reason. Available data show
that people are ready to travel far away
only for major health services, such as surgery, delivery or
c-section. To seek basic health services
(such as malaria diagnosis and treatment), people will usually
not travel farther than 5-10kms. In other
words, this “spill-over effect” will be limited to the villages
in the immediate neighborhood of the 8
districts.
Resp: Bank Stage: Appraisal Due Date : before
negotiations Status: Completed
2. Implementing Agency Risks (including fiduciary)
2.1. Capacity Rating: Moderate
Description: Ministry has substantial experience in managing
World Bank projects. While the Ministry has developed a
capacity in arranging vertical programs (HIV-AIDS and
malaria), there is room for improvement for cross-cutting
programs focusing on health system strengthening.
Risk Management: A Project Coordination Unit (PCU) has been set
up for the Project and is now
functional. The same unit will be used for implementing the AF
activities.
Resp: Bank Stage: Appraisal Due Date : Status: Completed
Risk Management: The PCU benefits from permanent support from a
technical assistance firm, which
is now recruited.
Resp: Bank Stage: Appraisal Due Date : Status: Completed
2.2. Governance Rating: Substantial
Description: Components 1 and 2 of the Project are using
output-based disbursement mechanisms. As such, there is a
risk that completion of outputs will not be measured
adequately. This risk is exacerbated by deficiencies in the
health information system and lack of social accountability
Risk Management: Component 3 will strengthen the health
information system.
Resp: Client Stage: Impl Due Date : by end of
Project Status: In progress
Risk Management : All outputs will be verified by an external
firm, which will use several data
-
37
mechanism. A similar risk may occur with the activities
financed through the AF.
collection methods for each output (to ensure triangulation)
Resp: Client Stage: Impl Due Date : by
effectiveness Status: Completed
Risk Management: In addition to the external verification (as
mentioned above), the Project will fund
Community-Based Organizations (CBOs) to contribute to the
external verification of outputs and to the
identification of the poorest patients.
Resp: Client Stage: Impl Due Date : by end of
Project Status: Not yet Due
3. Project Risks
3.1. Design Rating: Moderate
Description: PDO of the original Project may not be achieved
because of inadequate timeline and/or funding of the project
Description: The AF funding may have limited outcomes due
to barriers (for accessing health care services) other than
financial ones.
Description: The AF-funding (Malaria Free Health Care)
could boost the demand for health care services beyond the
existing supply capacity of the system
Risk Management: For estimating the most realistic contribution
of the project to the PDO indicators,
a Marginal Budgeting for Bottleneck (MBB) analysis has been
conducted with UNICEF support.
Additional data will be obtained at appraisal to set the PDO
targets at a realistic level.
Resp: Bank Stage: Prep Due Date : Status: Completed
In Benin in 2006, 76.4% of the population lived at less than 5km
to a health center (and 92.8% less than
15km). Geographical access is clearly not the main issue to
access care. The 2009 country status report
has also confirmed that cultural/social obstacles for accessing
health care are limited.
Resp: Bank Stage: Appraisal Due Date : Status: Completed
The above-mentioned 2009 Country Status Report has found the
Benin health system to be severely
underutilized (as demonstrated, for instance, by the low
productivity of health workers).
The main bottleneck is related to the number and quality of
community health workers, as they will be
heavily involved in providing free malaria care. This component
will be strengthened, through the
proposed AF.
Resp: Bank Stage: Appraisal Due Date : Status: Completed
3.2. Social & Environmental Rating: Low
Description: From the received RBF bonuses, health
facilities
may purchase medical equipment which might invariably
result
