FOR OFFICIAL USE ONLY - World Bankdocuments.worldbank.org/curated/en/...for official use only report...

Document of The World Bank

FOR OFFICIAL USE ONLY

Report No: 81009-CG

INTERNATIONAL DEVELOPMENT ASSOCIATION

PROJECT APPRAISAL DOCUMENT

ON A

PROPOSED CREDIT

IN THE AMOUNT OF SDR6.6 MILLION (US$10 MILLION EQUIVALENT)

AND

A PROPOSED GRANT IN THE AMOUNT OF US$10 MILLION

FROM THE MULTI-DONOR TRUST FUND FOR HEALTH RESULTS INNOVATION

TO THE

REPUBLIC OF CONGO

FOR A

HEALTH SYSTEM STRENGTHENING PROJECT II

November 25, 2013

AFTHW Country Department AFCC2 Africa Region 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.

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CURRENCY EQUIVALENTS

(Exchange Rate Effective October 31st, 2013)

Currency Unit = XAF XAF 500 = US$1

US$1 = SDR 1.53804

ABBREVIATIONS AND ACRONYMS

ACTs Artemisinin-based Combination Therapies ACV Agence de Contractualisation et Vérification (purchasing agency) ACVE Agence de Contre-Vérification Externe (external evaluation agency) AG Auditor General ANC Antenatal Care ART Anti-Retro-Viral Treatment AS Audit Statement ARI Acute Respiratory Infections AWP Annual Work Plan AWPB Annual Work Plans and Budgets BCC Behavior Change Communication BEmONC Basic Emergency Obstetric and Neonatal Care CBA Cost Benefit Analysis CBO Community Based Organization CCT Conditional Cash Transfer CD Communicable Diseases CDMT Medium term Expenditure Framework CEmONC Comprehensive Obstetric and Neonatal Care CFA Communauté Financière Africaine (African Monetary Community) CFAA Country Financial Accountability Assessment CFAF Franc de la Communauté Financière Africaine (African Financial

Community Franc) CHU Centre Hospitalier Universitaire (University Reference Hospital) CHW Community Health Worker CIFA Country Integrated Fiduciary Assessment CPIP Country Procurement Issue Paper CNLS Conseil National de Lutte contre le SIDA (National Council against

AIDS CNCS Comité national de coordination et suivi (National Committee for

Coordination and Monitoring) CNTS Centre National de Transfusion de Sang (National Blood Transfusion

Center) CODIR Comité de Direction (Regional hospital community co-management

committee) COGES Comité de Gestion pour l`Hopital de Base (First referral hospital

community co-management committee)

ii

COMEG Congolaise de Médicaments Esssentielset et Génériques (Congolese Company of Essential Generic Medicines)

COSA Health center community co-management committee CPIA Country Policy and Institutional Assessment CPIP Country Procurement Inssue Paper CPA Complementary Package of Activities CPR Cadre de Politique de Réinstallation (Relocation Framework Policy) CPS Country Program Strategy CQ Consultant Qualification CSI Cadre de Santé Intégré (Integrated Health Center) CSS Circo-conscription Socio Sanitaire (Health District) CT-PBF Cellule Technique -Performance Based Financing (Technical PBF

Unit) DA Designated account DAF Directorate of Administration and Finance DALYs Disability Adjusted Life Years DC Direct Contracting DDS Direction Départementale de la Santé (Regional Health Directorate) DEP Departement d’Etude et de Planification (Department of planning) DFH Department of Family Health DGAF Director General for Administration and Finance DGAP Director General for Administration and Planning DGE Direction Générale de l’Environnement (Directorate General for the

Environment) DGPD Direction Générale du Plan et Développement (Directorate General

for Development and Planning) DGRP Director General of Resources and Planning DGS Directeur Général de la Santé (Director General of Health) DGT Directeur Général du Trésor (Chief Executive Officer of Treasury) DHIS District Health Information System DHS Demographic and Health Survey DL Disbursement Letter DLM Direction of Disease Control DP Development Partners DPHLM Directorate of Pharmacies, Laboratories and Medicines DPI Direction du Plan et d’Investissement (Department of Planning and

Investment) DPT Diptheria, Pertussis, Tetanus DRC Direction Générale de la Construction (Directorate General of

Construction) DRE Direction Régionale de l'Environnement (Regional Directorate for the

Environment) DRF Direction des Ressources Financières (Directorate of Financial

Management) DRH Directorate of Human Resources ECOM Enquête Congolaise auprès des Ménages (Living Standards

iii

Measurement Survey) EDS Enquête Démographique et de Santé (DHS) EmONC Emergency Obstetric and Neonatal Care EOI Expression Of Interest EPI Expanded Program of Immunization ESMF Environmental and Social Management Framework EU European Union FB Fixed Budget FHD Family Health Directorate FM Financial Management FMA Financial Management Assessment FS Formation Sanitaire (Health facility) GDP Gross Domestic Product GPC General Procurement Notice GPN General Procurement Notice GOC Government of Congo GRO Grassroots Organizations HAU Health Administration Unit HBV Hepatitis B Virus HCV Hepatitis C Virus HIV/AIDS Human Immunodeficiency Virus-Acquired Immunodeficiency

Syndrome HIPC Heavily Indebted Poor Countries Initiative HMIS Health Management Information System HNP Health, Nutrition & Population HR Hôpital de Référence (Referral Hospital) HRH Human Resources for Health HRIS Human Resource Information System HRITF Health Results Innovation Trust Fund HSSDP Health Sector Services Development Project IA Internal Audit IC Individual Consultants ICB International Competitive Bidding ICR Implementation Completion Report ICT Information Communication Technology IDA International Development Association IE Impact Evaluation IEC Information Education, Communication IFC International Finance Coporation IFI Internationally Funded Projects IFR Interim Financial Report IGA Income Generating Activities IGF Inspection Générale des Finances (Office for General Inspection of

Finances) IGS Inspection Générale des Services du Ministère de la Santé (Office for

General Inspection of Service of the Ministry of Health)

iv

IMCI Integrated Management of Childhood Illnesses IMF International Monetary Fund IMR Infant Mortality Rate IP Indigenous Peoples IPF Investment Project Financing IPPF Indigenous Peoples Planning Framework IPT Intermittent Preventive Treatment ISA International Standards on Auditing ISDR Integrated Disease Surveillance and Response ISN Interim Strategy Note ISR Implementation Status and Results Report JAR Joint Annual Review JICA Japanese International Cooperation Agency KAP Knowledge Attitude and Practices LB Live births LBW Low Birth Weight LCS Least-cost selection LIB Limited International Bidding LLINs long-Lasting Insecticidal Nets M&E Monitoring and Evaluation MAP Multi-Country HIV/AIDS Program MCH Maternal and Child Health MDGs Millennium Development Goals MEB Marginal Excess Burden MFEB Ministry of Finance, Economy and Budget MICS Multiple Indicator Cluster Survey MOHP Ministry of Health and Population MIS Malaria Indicator Survey MOF Ministry of Finance MOHP Ministry of Health and Population MOU Memorandum of Understanding MPA Minimum Package of Activities MSASF Ministère de la Santé, Assistance Sociale et Familiale (Ministry of

Health, Social Services and Family Welfare) MTEF Medium-Term Expenditure Framework MTR Mid Term Review NC Niveau Central (Central level) NCB National Competitive Bidding NGO Non-Governmental Organizations NHA National Health Accounts NHDP National Health Development Plan NHP National Health Policy NO Non objection NPV Net Present Value NRM National Road Map OHADA Organisation pour l’Harmonisation en Afrique du Droits des Affaires

v

(African Business Rights Harmonization Organization) OMD Millennium Development Goals ONG Non-Governmental Organization OOP Out-of Pocket OP/BF Operational policy/Bank Financing OR Operations Research PBF Performance Based Financing PDO Project Development Objective PDSS Projet d’Appui des Services de Santé (Heath Service Delivery

Project) PEFA Public Expenditure and Financial Accountability PER Public Expenditure Review PFE Point Focal pour l’Environnement (Focal Point for Environment) PFM Procurement and Financial Management PIM Program Implementation Manual PMAE Paquet Minimum d’Activités Elargies (Minimum Package for

Enlarged Activities PMTCT Preventing Mother-to-child Transmission (HIV) PNDS Programme National de Développement de la Santé (National Health

Development Plan) PNLP Programme National de Lutte contre le Paludisme (National Malaria

Control Program)

PNM Post Neonatal Mortality PFM Public Financial Management PHC Primary Health Care PLVSS Projet de Lutte contre le VIH/SIDA et de Santé (HIV/AIDS Control

and Health Project POW Program Of Work PPP Public Private Partnership PPR Post Procurement Review PRCTG Projet du Renforcement des Capacités de Transparence et de

Gouvernance (Transparency and Governance Capacity Building Project)

PREM Poverty Reduction and Economic Management Network PRSP Poverty Reduction Strategy Paper PSE Paquet des Services de Santé Essentiels (Package of essential Health

services) PSDSS Projet Sectoriel de Développement des Services de la Santé (Health

Sector Services Development Project) QBS Quality Based Selection QCBS Quality and Cost Based Selection RBF Results Based Financing RC Relais Communautaire (Community health worker) RESEN Réseau National du Système Educatif (National Network Education

System)

vi

ROC Republic of Congo SBA Skilled Birth Attendant SBD Standard Bidding Document SDI Service Delivery Indicators SEP Secretaire Exécutif Permanent (Executive Permanent Secretary) SIL Sector Investment Lending SGS Secretaire Général de la Santé (General Secretary of Health) SNDE Sociéte Nationale de D éveloppement Des Eaux (National Water

Distribution) SNE Societe Nationale d’Electricité (National Electricity Distribution) SNPC Société Nationale des Pétroles du Congo (National Oil Company Of

Congo) SOE Statement of Expenditures SNIS Système National d’Information Sanitaire (Health Management

Information System) SP Sulfadoxine-pyrimethamine SPN Specific Procurement Notice SSS Single Source Selection STI Sexually Transmitted Infections TB Tuberculosis TF Trust Fund TFR Total Fertility Rate TOR Terms of Reference TSS Transitional Support Strategy TT Tetanus Toxoid UN United Nations UHC Universal Health Coverage UNDB United Nations Development Business UNFPA United Nations Fund for Population Activities UNICEF United Nations Children’s Fund VCT Voluntary counseling and testing (HIV) XAF Central African Franc WA Withdrawal Application WB World Bank WHO World Health Organization

Regional Vice President: Makhtar Diop Country Director: Eustache Ouayoro

Sector Director: Ritva S. Reinikka Sector Manager: Trina S. Haque

Task Team Leader: Hadia Nazem Samaha

vii

REPUBLIC OF CONGO

Health System Strengthening Project II (PDSS II)

TABLE OF CONTENTS

Page

I. STRATEGIC CONTEXT ......................................................................................................................... 1

A. Country Context ........................................................................................................................ 1

B. Sectoral and Institutional Context ............................................................................................. 2

C. Higher Level Objectives to which the Project Contributes ...................................................... 7

II. PROJECT DEVELOPMENT OBJECTIVES (PDO) .............................................................................. 9

A. Project Development Objectives ................................................................................................ 9

B. Project Beneficiaries .................................................................................................................. 9

C. PDO Level Results Indicators .................................................................................................... 9

III. PROJECT DESCRIPTION ..................................................................................................... 10

A. Project Component ................................................................................................................... 10

B. Project Financing...................................................................................................................... 16

C. Lessons Learned and Reflected in the Project Design ............................................................. 16

IV. IMPLEMENTATION ........................................................................................................................... 18

A. Institutional and Implementation Arrangements .................................................................... 18

B. Results Monitoring and Evaluation ........................................................................................ 19

C. Sustainability........................................................................................................................... 20

V. KEY RISKS AND MITIGATION MEASURES ................................................................... 21

A. Risk Ratings Summary Table ................................................................................................. 21

B. Overall Risk Rating Explanation ............................................................................................ 21

VI. APPRAISAL SUMMARY ................................................................................................................... 22

A. Economic and Financial Analysis ........................................................................................... 22

B. Technical .................................................................................................................................. 23

C. Financial Management ............................................................................................................. 24

D. Procurement ............................................................................................................................. 25

C. Social (including Safeguards) ................................................................................................. 26

D. Environment (including Safeguards) ...................................................................................... 27

viii

ANNEX 2: DETAILED PROJECT DESCRIPTION ................................................................................. 33

ANNEX 3: IMPLEMENTATION ARRANGEMENTS ............................................................................ 47

ANNEX 4: OPERATIONAL RISK ASSESSMENT FRAMEWORK (ORAF) ........................................ 71

ANNEX 5: IMPLEMENTATION SUPPORT PLAN ................................................................................ 76

ANNEX 6: PROJECT COST ..................................................................................................................... 79

ANNEX 7: WHAT IS PERFORMANCE BASED FINANCING ............................................................. 80

ANNEX 8: ECONOMIC AND FINANCIAL ANALYSIS ....................................................................... 87

ANNEX 9: PBF IMPACT EVALUATION ............................................................................................. 120

ANNEX 10: HUMAN RESOURCE ASSESSMENT .............................................................................. 125

ANNEX 11: PUBLIC AND COMMUNITY INVOLVEMENT IN HEALTH ....................................... 133

ANNEX 12: MAP OF THE REPUBLIC OF CONGO ............................................................................ 141

ix

PAD DATA SHEET

Congo, Republic of

Health Sector Project (P143849)

PROJECT APPRAISAL DOCUMENT

.

AFRICA

AFTHW

Report No.: PAD633

.

Basic Information

Project ID EA Category Team Leader

P143849 C - Not Required Hadia Nazem Samaha

Lending Instrument Fragile and/or Capacity Constraints [ ]

Investment Project Financing Financial Intermediaries [ ]

Series of Projects [ ]

Project Implementation Start Date

Project Implementation End Date

20-Dec-2013 28-Jun-2019

Expected Effectiveness Date Expected Closing Date

20-Mar-2014 28-Jun-2019

Joint IFC

No

Sector Manager Sector Director Country Director Regional Vice President

Trina S. Haque Ritva S. Reinikka Eustache Ouayoro Makhtar Diop

.

Borrower: Ministry of Finance

Responsible Agency: Ministry of Health and Population

Contact: Bernice Nsitou Title: Coordinator

Telephone No.:

242069808708 Email:

[email protected]

.

Project Financing Data(in USD Million)

[ ] Loan [ X ] Grant [ ] Guarantee

x

[ X ] Credit [ ] IDA Grant

[ ] Other

Total Project Cost: 120.00 Total Bank Financing: 10.00

Financing Gap: 0.00

.

Financing Source Amount

BORROWER/RECIPIENT 100.00

International Development Association (IDA)

10.00

Multi-Donor TF for Health Results Innovation

10.00

Total 120.00

.

Expected Disbursements (in USD Million)

Fiscal Year

2014 2015 2016 2017 2018 2019 0000 0000 0000

Annual 2.80 4.00 4.60 3.00 3.00 2.60 0.00 0.00 0.00

Cumulative

2.80 6.80 11.40 14.40 17.40 20.00 0.00 0.00 0.00

.

Proposed Development Objective(s)

The objective of the project is to increase utilization and quality of maternal and child health services in targeted areas.

.

Components

Component Name Cost (USD Millions)

Component 1: Improvement of utilization and quality of health services at health facilities through Performance-Based Financing (PBF).

107.50

Component 2: Strengthening Health Financing and Health Policy Capabilities.

12.50

.

Institutional Data

Sector Board

Health, Nutrition and Population

.

xi

Sectors / Climate Change

Sector (Maximum 5 and total % must equal 100)

Major Sector Sector % Adaptation Co-benefits %

Mitigation Co-benefits %

Health and other social services Health 100

Total 100

I certify that there is no Adaptation and Mitigation Climate Change Co-benefits information applicable to this project.

.

Themes

Theme (Maximum 5 and total % must equal 100)

Major theme Theme %

Human development Child health 25

Human development Health system performance 40

Human development Population and reproductive health 35

Total 100

.

Compliance

Policy

Does the project depart from the CAS in content or in other significant respects?

Yes [ ] No [ X ]

.

Does the project require any waivers of Bank policies? Yes [ ] No [ X ]

Have these been approved by Bank management? Yes [ ] No [ ]

Is approval for any policy waiver sought from the Board? Yes [ ] No [ X ]

Does the project meet the Regional criteria for readiness for implementation?

Yes [ X ] No [ ]

.

Safeguard Policies Triggered by the Project Yes No

Environmental Assessment OP/BP 4.01 X

Natural Habitats OP/BP 4.04 X

Forests OP/BP 4.36 X

Pest Management OP 4.09 X

xii

Physical Cultural Resources OP/BP 4.11 X

Indigenous Peoples OP/BP 4.10 X

Involuntary Resettlement OP/BP 4.12 X

Safety of Dams OP/BP 4.37 X

Projects on International Waterways OP/BP 7.50 X

Projects in Disputed Areas OP/BP 7.60 X

.

Legal Covenants

Name Recurrent Due Date Frequency

Financial and Accounting Software should be acquired and installed.

17-Jul-2014

Description of Covenant

The Recipient shall, not later than three (3) months after the Effective Date: (i) acquire in accordance with the provisions of Section III of Schedule 2 to the Financing Agreement, and thereafter install, appropriate financial management/accounting software to facilitate the proper maintenance of its financial management system referred to in Part B.1 of Section II to the Financing Agreement; and (ii) provide financial management Training for staff involved in financial management of the Project, under terms of reference acceptable to the Association


External Auditor. 10-Jul-2014


To facilitate the carrying out of independent audits under Part B.3 of Section II to the Financing Agreement, the Recipient shall, not later than three (3) months after the Effective Date, appoint an external auditor, in accordance with the provisions of Section III.C of Schedule 2 to the Financing Agreement.


Training of Procurement Staff. 17-Apr-2015


The Recipient shall, not later than twelve (12) months after the Effective Date, provide training for the Project’s procurement staff, under terms of reference acceptable to the Association.


Update of procurement filing and record keeping system

17-Oct-2014


The Recipient shall, not later than six (6) months after the Effective Date, update, for purposes of the Project, its procurement filing and record keeping system, in form and substance acceptable to the Association.

xiii


Procurement Audit 30-Dec-2015


Without limitation upon the provisions of Part B.3 of this Section III, the Recipient shall, in each Fiscal Year (“FY”) beginning FY2016, carry out under terms of reference satisfactory to the Association, an audit of contracts procured in the preceding FY and furnish said audit to the Association not later than six months after the end of the FY to which said audit relates.


Mid-Term Review 17-Oct-2016


The Recipient shall, not later than thirty (30) months after the Effective Date, undertake, in conjunction with all agencies involved in the Project, a comprehensive mid-term review of the Project (Refer to Section II A of FA).

.

Conditions

Name Type

Release of the first tranche of the counterpart funding Effectiveness

Description of Condition

The Recipient has deposited 10,000,000,000 CFA Francs into the Project Counterpart Funds Account, in accordance with the provisions of Section I.G of Schedule 2 to the Financing Agreement.

Name Type

The Grant Agreement has been executed and delivered Effectiveness

Description of Condition

The Grant Agreement has been executed and delivered and all conditions precedent to its effectiveness or to the right of the Recipient to make withdrawals under it (other than the effectiveness of this Agreement) have been fulfilled.

Team Composition

Bank Staff

Name Title Specialization Unit

Hadia Nazem Samaha Senior Operations Officer

Team Lead AFTHW

Tazeem Mawji Consultant Consultant AFTHW

Antoine V. Lema Senior Social Development Specialist

Senior Social Development Specialist

AFTCS

Benjamin P. Lead Public Health Lead Public Health AFTHW

xiv

Loevinsohn Specialist Specialist

Bella Lelouma Diallo Sr Financial Management Specialist

Sr Financial Management Specialist

AFTMW

Mahamat Goadi Louani

Senior Human Development Specialist

Senior Human Development Specialist

AFTHW

Aissatou Diallo Senior Finance Officer Senior Finance Officer CTRLA

Sariette Jene M. C. Jippe

Program Assistant Program Assistant AFTHW

Mohamed Ali Kamil Senior Health Specialist

Senior Health Specialist

AFTHE

Gyorgy Bela Fritsche Senior Health Specialist


AFTHW

Christine Makori Senior Counsel Legal LEGAM

Clement Tukeba Lessa Kimpuni

Senior Procurement Specialist

Senior Procurement Specialist

AFTPW

Paul Jacob Robyn E T Consultant E T Consultant AFTHW

Luc Laviolette Sector Leader Sector Leader AFTHD

Maud Juquois E T Consultant E T Consultant AFTHW

Leonardo Cubillos-Turriago



WBIHS

Josiane Maloueki Louzolo

Team Assistant Team Assistant AFMCG

Henri Joel Nkuepo E T Consultant E T Consultant LEGAM

Eric Christian Thibaut Mallard



HDNHE

Non Bank Staff

Name Title Office Phone City

Ricardo Bitran Economist Santiago

Gunther Fink Impact Evaluation Specialist

Cambridge

.

Locations

Country First Administrative Division

Location Planned

Actual Comments

1

I. STRATEGIC CONTEXT

A. Country Context

1. The Republic of Congo (ROC) is growing and urbanizing. ROC is a lower middle income country with vast oil revenues and a small population, estimated at 4.31 million in 2012. ROC has one of the fastest economic growth rates in Sub-Saharan Africa (average 5.8 percent over 2007-2012) and has the potential to become an emerging economy over the next decade. Sixty two percent of the population lives in urban areas, half of which is living in two main urban centers, Brazzaville and Pointe Noire. Nearly forty percent of Congo’s population is under 15, and growing at a rate of three percent per year. This trend will lead to a doubling of the population in 25 years.

2. ROC’s weak institutions delay progress on social and economic growth. Many years of conflict and unstable governments have severely weakened the country’s administration, eroded public accountability, and undercut publicly funded services. This decline is reflected in the inability of the administration to transform its economic growth into better access to basic services and improved social outcomes for the majority of the population. Mindful of the need to modernize public administration and its human resources, the Government of Congo (GOC) has initiated a civil service reform (including deconcentration) and allocated additional resources to the civil service apparatus.

3. In contrast with the country’s high economic growth, poverty indicators remain high, especially among the rural poor. Preliminary data from the 2011 ECOM (Living Standards Measurement Survey) revealed that from 2005 to 2011 the overall poverty rate has dropped by 4 percentage points to 46.5 percent. This average decline masks important regional differences. In the urban areas, poverty is widespread (around 40 percent of the population lives on less than US$22 per day). In the rural areas, poverty levels are even higher (approximately 70 percent of the population lives on less than US$2 a day). In addition, the economy is characterized by low earnings for the majority of the population, with the situation particularly dire for those in the informal sector, where monthly earnings are barely over US$100 a month, in a country with a high cost of living. The political economy is such that no incentives are in place to promote results for the poor.

4. In the past seven years, there has been uneven progress toward the Millenium Development Goals (MDGs). There are significant improvements in (i) MDG 2, achieving universal primary education, completion rates have increased to 83 percent (target is 100 percent) but there is no indication of significant quality improvements, (ii) MDG 3 which promotes gender equality, the ratio of girls/boys in primary schools has improved to 0.97 (target is 1/1), and (iii) MDG 4 which aims to reduce child mortality, the under-five mortality rate is down to 68 per 1000 (target is 35 per 1000). The likelihood that these three targets will be achieved by 2015 is quite low, assuming that current trends continue. In contrast, the likelihood

1 UNFPA estimate in 2012. 2 The national threshold used in the 2011 ECOM for having the poverty rate of 45.6 percent is around US$2 a day (exactly XAF 994).

2

that extreme poverty and hunger will be eradicated (MDG 1), maternal health indicators will be improved (MDG 5), HIV/AIDS will be halted and reversed, universal access to treatment will be achieved (MDG 6) and that half the number of people with access to safe drinking water and sanitation (MDG 7) targets will be reached by 2015 is low. Overall, the performance of the health sector in ROC remains poor.

B. Sectoral and Institutional Context 5. Congo’s progress towards better health outcomes is slow. According to the 2012 Demographic Health Survey (DHS) data, maternal mortality ratio remains high, at 426 per 100,000 live births and the under-five mortality and infant mortality rates are 68 per 1000 live births and 39 per 1000 live births respectively. Neonatal mortality on the other hand showed a small decrease from 28 to 22 per 1000. Similarly, the adolescent fertility rate for 15–19 year olds remains high at 147 per 1,000 women in the 2011-12 DHS. In addition, ROC suffers from a general chronic malnutrition prevalence of 24.4 percent (stunting), including areas in which 38.6 percent of all children less than 5 years old are chronically malnourished.

6. Reproductive health indicators are worse than expected. The maternal mortality ratio, total fertility rate and contraceptive prevalence rate, which are widely used to assess the vulnerabilities of women and children, fall well below those expected in a low middle income country. With a Total Fertility Rate (TFR) of 5.1 in 2012, ROC belongs to the group of twenty countries (all of them low income, besides ROC) with the highest fertility rates in the world. Notably, ROC’s TFR has increased from 4.8 in 2005 to 5.1 in 2012 despite an increase in the usage of modern contraception (see footnote 1). This increase took place in both rural and urban areas from 2005 to 2012. In comparison, Ghana has a TFR of 4 and emerging economies (such as Morocco, Egypt, Tunisia, Vietnam) have TFRs between 2 and 3, with modern contraception rates between 60 and 85 percent. Table 1 summarizes findings from DHS surveys between 2005 and 2012. 7. The HIV/AIDS epidemic is being successfully addressed by the national program, which benefited, inter alia, from Bank support. The current prevalence rate among adults is estimated at 3.3 percent (down from 4.2 percent in 2005) and the incidence rate (new cases) is below 1 percent. HIV prevalence in pregnant women attending antenatal care is 2.7 percent (down from 5.2 percent in 2005). Access to Anti-Retroviral Treatment (ART) is estimated to be at 40 percent and will require continuous efforts from the government to reach universal access.

8. The availability and allocation of resources in the health sector is a major concern in ROC. While ROC ranks among the countries with the highest per capita income in Sub-Saharan Africa (SSA) (rank of 35 out of 45 countries), its total health expenditure per capita, at 2.5 percent of gros domestic product (GDP) in 2011, is the second lowest in the region and fifth lowest in the world. Public health expenditure as a share of GDP is the 8th lowest regionally and the country’s reliance on out-of-pocket health spending out of total health financing, at 64 percent, is among the highest (rank of 39).

Table 1: Reproductive health indicators, ROC, 2005 and 2012

2005 2012Fertility Rate (TFR) 4.8 5.1 Urban areas (TFR) 3.8 4.5 Rural Areas (TFR) 6.1 6.5 Modern Contraception % 13 22

3

9. According to the ongoing Public Expenditure Review for Health, government spending on hospital care is twice as high as spending on ambulatory care. This skewed allocation results in inadequate financial protection for lower income groups against high-cost health treatments. The lack of health care financing in ROC is much more severe than the lack of human resources and hospital beds at the country level, as is illustrated in the Figure 4 below. At the local level, however, the lack of resources, both financial, human, and physical, is compounded by a poor territorial allocation of these resources.

Figure 1: The relative insufficiency of financial and other resources for health in ROC

10. Out of pocket spending is high due to the imposition of user fees and a charge formedicines. These high costs prohibit utilization of government health facilities, especially among the poor. Currently government spending in the health sector is very

Table 2: Income and health spending indicators for ROC ranked among all countries in SSA

Indicator

Rank (1=minimum; 45=maximum) Value

GDP per capita, PPP (constant 2005 international US$) 35 3,850 Health expenditure, total (% of GDP) 2 2.5% Health expenditure, public (% of GDP) 6 1.7%3 Out of pocket expenditure (% of total health expenditure) 39 644%

3 The team has been faced with conflicting sources of information regarding the magnitude and share of health expenditure for ROC. The 1.7% comes from the DataBank, a database we used for the purposes of comparison with other countries in Sub-Saharan Africa. 4 The latest NHA reports that OOPS is 37.2 %. However estimates based on the most recent ECOM2 HHS imply that OOPS is actually much higher, close to 69% reported in the databank.

CongoNigeria

South Africa

Kenya

0

5

10

15

20

25

30

35

40

45

50

0

10

20

30

40

50

60

70

80

90

100

Per capitaGDP (dollarsPPP 2011)

Total healthexpenditure as

% of GDP

Govermenthealth

expenditure as% of

governmentbudget

Hospital beds(per 1,000

people)

Doctors (per1,000 people)

Nurses (per1,000 people)

Ran

k

Qui

ntile

4

low, (1.7 percent of total GDP, and US$39 per capita per year – National Health Accounts (NHA- 2009-2010) this means that health facility budgets are insufficient to cover the actual costs of services. In order to supplement the limited resources, the health ministry has adopted a cost-recovery policy at the facility level, thus enabling health facilities to raise their revenue to cover their operational costs. In 2010, 37 percent of all financing of government health care providers comes from user fees (NHA 2009-2010). User fees are set for curative services as well as for preventative services such as growth monitoring for children under 5, ante-natal and post-natal care. It also includes payment for most medicines (except for medicines for HIV, TB and malaria for children under five years of age and for pregnant women), hence dramatically increasing the cost of care for patients attending public sector facilities. This in turn leads to lower utilization of services especially among the rural poor who are unable to afford the care and the medicines.

11. The private sector delivers about one third of all health services and one half of all ambulatory care. It has the potential to help the country improve its primary health care coverage if a formal public- private- partnership were to be established (Private Health Sector survey – 2011). The private sector5 provides about half of all curative care in urban areas which houses about 62 percent of the population of ROC, however it is very expensive. Furthermore, whereas the private sector (which is a mix of providers, private for profit, private non-for profit and pharmacies) provides 70 percent of curative care visits at the primary level in urban areas, it does not offer a complete package of services at the primary level nor does it offer hospital services. The relatively high use of private services is explained by more flexible payment mechanisms including delayed payments or even free services (6 percent of services were provided free of charge at private health facilities). The main reasons for not using the public sector include low quality of care, poor attitude of health workers, requests for informal payments, and services not being offered if the patient has no money. Private sector health centers are largely inexistent in rural areas and due to their relatively high costs, are inaccessible for the majority of the poor.

12. Utilization rates in the public sector remain low both in rural and urban areas. The average Congolese makes 0.20 curative consultations with a health care provider per year. This is equivalent to just one visit every five years. This low level is attributed in part to poor quality of health services, lack of clear “catchment” areas, and high user fees. Indeed, when closely examining the quality issues, one notes the following obstacles to quality health services: (i) the performance of health workers (absenteeism, quality of care, poor on-the job training, poor initial training at the school level, interpersonal skills) is weak; (ii) health facilities have limited funding for ensuring availability of drugs and supplies; (iii) the type of services available at the health facility level is limited; and (iv) the availability of the service in terms of convenience (operating hours, geographical proximity), and hotel services (such as meals, gardening, laundry) are inadequate, further reducing the likelihood of seeking health services from the formal health sector. Furthermore, use of traditional medicine and care from the informal sector contribute to the observed low utilization in the formal sector.

13. The distribution of human resources within the country is inequitable. The health

5Etude sur le secteur privé de la santé en République du Congo, Results for Development Institute, HERA (2011).

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institutional context is characterized by inadequate capacity for planning, poor motivation of health workers, and weak health systems, all of which culminate in the poor quality of service delivery. Further, the distribution of health personnel is unequal with higher concentrations of personnel in the two main cities, Brazzaville and Pointe-Noire; 68 percent of ROC’s population lives in these two cities but 93 percent of specialized doctors, 73 percent of general practitioners, 61 percent of nurses, 78 percent of midwives and 85 percent of pharmacists work in these 2 cities. Training, recruitment and allocation of health workers are managed by 5 different Ministries; these Ministries do not coordinate among themselves. Consequently, health workers do not receive adequate in-service training and are not deployed to health facilities that need their specialized skills, thus rural facilities which need certain specialists have vacant positions and urban facilities which do not need additional specialists have more positions than they require (see table 3). (See Annex 10).

Table 3: Number and densities (per 1,000 people) of qualified health workers per region

Regions Specialists

General Practitioners Midwives Nurses

Num. Density Num. Density Num. Density Num. Density Kouilou 0 - 2 0,02 25 0,24 163 1,57 Niari 5 0,019 12 0,05 52 0,20 680 2,61 Lékoumou 2 0,018 2 0,02 12 0,11 229 2,11 Bouenza 0 - 17 0,05 30 0,09 470 1,35 Pool 1 0,004 7 0,03 46 0,17 349 1,31 Plateaux 4 0,020 9 0,05 27 0,14 203 1,03 Cuvette 0 - 14 0,08 34 0,19 535 3,05 Cuvette-Ouest 0 - 8 0,10 8 0,10 154 1,87 Sangha 0 - 7 0,07 19 0,20 99 1,03 Likouala 2 0,012 9 0,05 19 0,11 173 1,00 Brazzaville 150 0,097 136 0,09 647 0,42 3098 2,00 Pointe-Noire 36 0,045 100 0,12 296 0,37 1713 2,13 Total 200 0,048 323 0,08 1215 0,29 7866 1,89

14. Availability of drugs at an accessible cost is uneven across health facilities in ROC.This is mainly due to the fact that health facilities procure drugs from various sources including the private sector. The private pharmaceutical market is not well regulated and the price of the drugs on the market is relatively high while the quality of the drugs is suspect. Field visits show that on the whole, more than half of all drugs and medical consumables present have been procured from the private market, while about half of all products are generic products from the Congolaise de Médicaments Esssentiels et Génériques (COMEG). The products from COMEG are known to be of good quality and affordable, mostly from well-known suppliers such as IDA (Drug Company) and Missionpharma. Field observations show that the cost of the non-COMEG drugs is between 6 and 10 times higher than those of similar products originating from COMEG.

15. Health outcomes are poor throughout the country and there are large inequalities

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among different socio-economic groups. (Table 4). While there is a modest difference between urban and rural child mortality rates, there is a wide gap between the richest income quintile and the remaining population. This suggests that reducing preventable mortality will require a comprehensive approach that reaches segments of the population that are most in need.

Table 4: Mortality rates of children under certain socio-economic characteristics Congo, 2011-2012

Neonatal mortality rate (NMR)

Post Neonatal Mortality (PNM)1

Infant Mortality (1q0)

Child mortality (4q1)

Under 5 mortality rate (5q0)

Areas Urban 26 18 45 34 77 Rural 21 29 51 39 88 Socio-economic quintiles The poorest 22 30 52 40 89 Second 29 26 55 46 98 Third 24 18 42 41 81 Fourth 26 19 46 30 74 The richest 19 17 36 19 54

Source: Ministry of Economy, Finance, Planning, and Public Portfolio Integration and National Center for Statistics and Economic Studies (CNSEE) (2013) DHSII 2011-2012.

16. The Government has recently taken clear actions that show its commitment to achieving Universal Health Coverage (UHC). The government of ROC has recently proposed a new law seeking to achieve UHC in the country (see law proposal named “régime d’assurance maladie universelle (RAMU) en République du Congo”). While per capita income in ROC is similar to that of other countries that have made important progress in moving toward UHC (such as Vietnam), in ROC, the institutional setting and the current development of its health system may not yet be ripe to engage in the active promotion of UHC. Despite this, the proposed project is expected to bring about changes that will facilitate ROC’s transition towards a health insurance system and UHC. Several important steps are necessary prerequisites to the promotion of UHC. They include: (i) the formulation and adoption of a benefits package; (ii) the development and nationwide implementation of standards of care; (iii) the use of mechanisms to identify and target the poor and vulnerable; (iv) the significant expansion of government health spending; (v) the improvement in the formulation and allocation of the government’s health budget, (vi) a more equitable and rational distribution of health staff along the territory; and (vii) the adoption of provider payment methods that promote productive efficiency. The current project, through its components and subcomponents, will support the development and implementation of several of the above health system components, thus facilitating the path towards UHC.

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C. Higher Level Objectives to which the Project Contributes 17. The International Development Association’s (IDA’s) engagement in the health sector is critical to unlocking the socio-economic potential of ROC and reducing poverty. While ROC over the past 5 years has seen an improvement in some of its health MDGs, there is still a dire need for more investment in health -- especially in maternal, child and reproductive health -- in order to reduce poverty and reach its MDGs targets by 2015. The health situation remains critical. Due to continued high levels of fertility, the need for health (and education) investment to create a productive workforce is increasing. The availability of basic health services, including reproductive health services, can potentially make an important contribution to increasing economic growth and welfare by empowering women and lowering the dependency ratio. The gravity of the health situation and its catastrophic financial risks on the population combined with the small number of donors in the health sector underscore the importance of IDA’s role in improving the livelihood of the human capital and thus contributing to economic growth and poverty reduction in ROC. IDA’s engagement contributes to increasing shared prosperity and reducing extreme poverty by its focus on basic health services for all and especially the poor while protecting the poorest of the poor for castastrophic health expenses.

18. The proposed project is aligned with ROC’s Poverty Reduction Strategy Paper (PRSP), ROC’s National Health Development Plan (NHDP II) and the National Health Policy (NHP). The project is expected to contribute to strengthening and extending the delivery of maternal and child health services, especially to the poorest, and thereby contributing to the achievement of MDGs 1, 4, 5 and 6 (‘health related MDGs’) to reduce malnutrition, child mortality, communicable diseases such as HIV/AIDS and TB, and improve maternal health. In so doing, the project will contribute to an increase in access to basic health services and will strengthen human capital, which is a specific long-term objective outlined in the PRSP. By focusing on MDGs 4 and 5, the project will indirectly contribute to women empowerment (MDG 3). The proposed project also directly focuses on building local capacity and promoting partnerships with local civil society and seeks to create a conducive environment to improve health by strengthening management capacity. Both of these are priorities outlined in the NHP and NHDP.

19. Client interest in the proposed project is high. The Ministry of Health and Population (MOHP) requested the World Bank to help the Government achieve the MDGs and provide the technical assistance required to best advise how to achieve UHC. This highlights the Governments strong motivation in co-financing the project with US$100 million whereas the Bank contribution is US$20 million (IDA and Health Results Innovation Trust Fund-HRITF). The MOHP also requested the World Bank provide support to scale up performance-based financing (PBF)6 in the health sector. Much of the technical groundwork for PBF has already been developed at the leadership level through policy dialogue and technical discussions. The project is strengthening and extending the existing approach to PBF that aims to improve the quality and quantity of health services.

6 See Annex 7 for a full definition of PBF and its lessons learned.

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20. ROC has a short, albeit useful in-country experience with PBF and this experience will inform the scale-up. A PBF pilot has been implemented in three departments (Niari, Pool, and Plateaux) since January 2012. The pilot project is financed by the current Bank health project (PDDS). The international non-governmental organization CORDAID was selected to implement this pilot project, using a private-purchaser approach. A separate agency, EPOS assisted by Brandeis University was recruited to document the impact of the PBF intervention, and also to monitor the effectiveness of the project implementation. The project is designed based on current best practice, and implemented by an experienced team of international (Southern) and national PBF experts. Contracts have been signed with 3 health department units (Pool, Niari, and Plateau); 9 district health teams, 7 hospitals and 73 health centers. During the first nine-months of operations (October 2012 - June 2013) key essential health services have started to increase significantly; additionally the quality of health services, as well as the performance of the health administration at district and departmental levels have improved noticeably.7

21. The Government of ROC has decided to invest significantly in this new approach due to the positive results that are emerging from the PBF pilot and based on the recent policy and technical dialogue. The dialogue has shown the Government how PBF has been successfully implemented in other African countries, and improved the performance of their respective health system especially maternal and child health services (i.e. Burundi, Cameroon, and Rwanda). Given their political commitment to achieving the MDGs, the Government recognizes that a sizable capital investment twinned with technical assistance from the World Bank, could help them achieve their objective and improve the performance of their health system. Through ongoing policy dialogue, the MOHP has come to appreciate the merits of PBF especially its ability to create a more efficient, equitable and better quality health system while improving transparency, accountability, and governance.

22. The proposed operation is fully in line with the Bank’s partnership with the Republic of Congo for FY13–FY16 which aims to help Congo use its large oil revenues to diversify its economy and improve its social outcomes. The proposed operation can help the Congo to achieve the opportunity - as underscored by the Country Program Strategy (CPS) – of using its oil wealth to build a more diversified and competitive economy while reducing poverty and improving social outcomes, most importantly meeting their MDG targets. The proposed operation will help to strengthen the financing and governance of the health sector in the country by building on the current investment and working with the Ministry of Health and Population and the international partners to implement PBF and guide the Government in its desire to achieve UHC in the next six years.

23. The Government and the Bank considered the option of sectoral budget support operation (or a PforR). However, the Bank’s assessment is that the MOHP is not yet ready for such streamlined support. Rather, the Project will strive to strengthen the MOHP capacities (especially regarding financial management, M&E and a culture of performance management and rewards) so that such an operation may be an option in the future.

7 EPOS-Brandeis mid-term evaluation, April 2013, and also field observations

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II. PROJECT DEVELOPMENT OBJECTIVES (PDO)

A. Project Development Objectives

24. The objective of the Project is to increase utilization and quality of maternal and child health services in targeted areas.

B. Project Beneficiaries

25. The geographical areas where the project will be implemented covers 7 out of 12 health Departments in ROC (Brazzaville -1,621,713 inhabitants; Pointe Noire: 844,679; Bouenza: 364,959; Cuvette: 184,259; Niari: 273,089; Pool: 279,375; and Plateau: 206,160) for a total population of 3.8 million people (86 percent of the population). The direct beneficiaries include women and children under 5 and hence represent about 1.9 million people.

26. The 7 Departments were chosen on the following basis: 1) inclusion of the 3 departments (Niari, Cuvette, et Pool) where the PBF pilot is being implemented; 2) inclusion of the 2 “control” departments (Bouenza and Cuvette ) which are part of the pilot PBF; and 3) introduction of Urban PBF hence Brazzaville and Pointe Noire.

C. PDO Level Results Indicators 27. The proposed set of PDO indicators covers all aspects of the operation.8 Additional intermediate level indicators for progress monitoring and results reporting are described in Annex 1.

(i) Increased utilization of maternal and child services will be measured using the following PDO level indicators

1. Number of children fully immunized 2. Percentage of pregnant women having at least 3 antenatal care visits before delivery 3. Percentage of children aged between 6 months and 59 months receiving nutritional services 4. New curative consultation per capita and per year;

(ii) Improvement in quality of health care in the selected regions will be measured using:

5. Average score of the quality checklist.9 6. The number of direct project beneficiaries, of which female (percentage), would also be part of the PDO level indicators covering both components 1 and 2.

8 Data will be dis-aggregated by gender as appropriate. 9 The quality check list is a comprehensive quality assessment of the quality in a health facility, including more than a hundred of items related to the following aspects: hygiene, drug availability, clinical care, equipment availability, drug management, financial management, and laboratory. The checklist can be found on www://nphcda.thenewtechs.com.

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III. PROJECT DESCRIPTION

A. Project Component Component 1: Improvement of utilization and quality of health services at health facilities through Performance-Based Financing – Total costs including contingencies US$107.5 million (of which IDA = US$8.95 million, HRITF = US$8.95 million and Government = US$89.60 million) 28. A PBF approach (whereby PBF Grant Agreements will be signed with the health facilities and whereby PBF Grants will be paid based on results achieved) will be introduced throughout the entire health system covering health facilities. The PBF Grants will be introduced at first level referral hospitals, and health administration at district (CSS), departmental (DDS) and select departments at central Ministry of Health (MOHP) level. Local civil society organizations will be selected and trained to become contract management and verification agents. Grassroots organizations will be engaged to measure service use and client satisfaction and community health committees (COSAs) will be strengthened. As there is a considerable and growing private sector in ROC, Component 1 will also strengthen public-private engagements in the health sector via PBF whereby private for profit facilities will be contracted out for the provision of quality health services. Work with the private sector will be further developed in collaboration with International Finance Coporation (IFC) and will ensure that public-private partnership interventions to strengthen the health system will be integrated. 29. Component 1 will help set the foundation for Universal Health Coverage (UHC) by promoting the adoption of benefit packages at the ambulatory and hospital levels, developing a system of exemptions and waivers for health services, and adopting a provider payment system that promotes a greater number and better quality of services, and empowers communities to influence the performance of the health system.

Subcomponent 1.1: Provision of PBF Grants to Health Services Providers for delivery of Health Subprojects (MPA and CPA), to women and children - Total costs including contingencies US$87.5 million (of which IDA = US$7.27 million, HRITF = US$7.27 million and Government = US$72.98 million) 30. Two health service packages (or Health Sub-projects) have been designed for use in the PBF approach. They are the Minimum Package of Activities (MPA), which contains 23 preventive and curative health services for the community and health center level, and the Complementary Package of Activities (CPA), with 18 services for the first level hospitals. These benefit packages were designed during a technical meeting in Brazzaville 24th July 2013 and are based on international best practice. About 60-70 percent of all resources are allocated to pay for health services for women and children. Hence, the services selected provide good potential for accelerating ROC’s achievements for the health related MDGs 4 and 5 (see the list of services in Annex 2). However, considering the burden of disease in ROC.10 (Global Burden of Disease

10 According to the 2010 Global Burden of Disease studies, for the first ten conditions that cause the highest burden of disease, Congo ranks the worst (15th ranking) for eight conditions among its comparator countries. These

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Study 2010), the project will also focus on MDG 1 (which targets nutrition) and MDG 6 (which targets infectious conditions such as HIV/AIDS and tuberculosis.

31. A quantified quality checklist11 will be designed for each level of the service package incorporating lessons learned during the pilot and taking into account international best practice. For each level, for health centers and hospitals, a quantified quality checklist will be designed. The checklists used in the PBF pilot will provide the foundation for these checklists, measures with increased weights given to process measures. They will also introduce measures related to rational prescribing of generic drugs, essential drug management and tracer drugs.

32. Intersectoral collaboration with a new Social Protection Program: The social protection sector is planning the LISUNGI safety nets sytem project in ROC (LISUNGI). This project will pilot active targeting of the poor using existing community mechanisms to identify beneficiaries for project subsidies and to stimulate access to health services. The LISUNGI project is planned to have a national poverty registration system (known as the Unified Registry) for enrollment into conditional cash transfer (CCT) programs linked to health and education behavior. There is large potential for complementarity, and for economies of scale. It is expected in the long term that the health sector will benefit from LISUNGI’s Unified Registry system for identification of the poor who will in turn benefit from fee-exemptions for essential health services targeted by PBF. Subcomponent 1.2: PBF Capacity Development Subprojects focusing on Governance, purchasing, coaching and strengthening health administration - Total costs including contingencies US$20.0 million (of which IDA = US$1.68 million, HRITF = US$1.68 million and Government = US$16.68 million) 33. Contract management and verification: a purchasing arrangement will be created covering batches of 500,000 persons. An innovative strategy will be followed to build local capacity in PBF contract management and verification functions (PBF Grant Agreements). Local civil society organizations (ACV - Agence de Contractualisation et Verification) will be selected through a contracting process. Their capacity for PBF contract management, verification, counter-verification and coaching will be built through PBF experts housed in the PBF unit (Cellule Technique du PBF – CT-PBF) in the MOHP. These local organizations will be under a performance contract with the CT-PBF in which the timely and correct execution of their tasks will be measured and rewarded through a quarterly performance framework applied by the CT-PBF.

34. Performance frameworks (or Capacity Development Grants) will also be introduced throughout the health system and will hold health administration units (HAU) accountable for services performed through incentive mechanisms. Internal performance frameworks conditions are HIV/AIDS, Malaria, Diarrheal diseases, Lower respiratory tract infections, Protein energy malnutrition, Road injuries, Congenital anomalies and Meningitis. 11 The Quantitative quality checklist serves 2 key functions: it has a system strengthening effect and provides supervisory health teams with a rigorous tool to assist health facilities to adhere to national norms and guidelines. The quantitative quality checklist is applied once per quarter to each PBF facility by CSS/DDS, who is under a performance contract to carry out this function. The checklist will be part of the PBF manual which will be be developed by project Effectiveness expected in April 2014.

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contracts will clearly outline the expected performance of the different HAU vis-à-vis their roles in the health system and lead to successfully scaled up PBF approaches. The Performance frameworks are assessed quarterly through a mix of internal and external verifications before payment is made (ex-ante), and are randomly counter-verified (ex-post; after payment) using a third party agent to ensure reliability of the ex-ante performance assessments. A system of tested penalties will be instituted to discourage gaming. The determination of the fees associated with each service will described in the PBF manual. For the internal verification, the Health Verification Team will verify on a quarterly basis: (i) the quality and quantity of the Minimum Package of Activities and/or of the Complementary Package of Activities, respectively, delivered under a Health Subproject for which a PBF Grant is requested; and (ii) the performance of implementing agencies (including Health Administration Units) under the Performance Frameworks.

35. The CT-PBF unit will coordinate and manage the project in close collaboration with the various technical units with the MoHP. The CT-PBF will be staffed by a mix of government staff and consultants recruited through a merit-based process (see more about CT-PBF in implementation arrangements). 36. Verification and counter-verification of the DDS, ACV, CSS and drug regulatory authority/MOHP HMIS/MOHP department performance will occur each quarter. An external evaluation agency (Agence de Contre-Vérification Externe - ACVE) will assess the performance of the ACV, DDS, CSS, HMIS department/MOHP and the drug regulatory authority/MOHP. This agency will be recruited under component 2. This ACVE will carry out each quarter, independent verifications of: (i) the delivery of the Minimum Package of Activities and/or of the Complementary Package of Activities, respectively, by HSPs under respective Health Subprojects, and (ii) the performance of implementing agencies (including Health Administration Units) under the Performance Frameworks. In addition, the ACV will carry out each quarter:

a. a verification of the performance of the HMIS and drug regulatory authority/MOHP; b. a counter-verification of the quantity of services through a lot quality assurance

sampling protocol with intense use of mobile phone technology and a community client satisfaction survey component;

c. counter-verification of a random sample of CSS and DDS performance assessments; d. counter-verify a random sample of health center quality checklists e. In the case of discrepancies surpassing 5 percent score in any of the verified samples

(whether quantity, quality or performance frameworks for the CSS), a significant penalty will be imposed on the performance earnings of the institution that reported this performance. The penalties for fraud will be clearly outlined in the various contracts and procedures and will be detailed in the PBF manual.

37. Communities will be empowered in their roles as co-managers of health services. This will be a two-way process with both PDSS II (supply side) and community (demand side) perspectives. Communities will be informed through information campaigns as to what services to expect from the CIS and hospitals. Furthermore, communities will be pooled into assessing the quality of the health services provided.

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Component 2: Strengthening Health Financing and Health Policy Capabilities – Total costs including contingencies US$12.5 million – (of which IDA = US$1.05 million, HRITF = US$1.05 million and Government = US$10.4 million) 38. Its aim is to strengthen health care financing policy and practice in ROC both to improve equity and efficiency in health financing and to pave the way for UHC. Accordingly, the component includes the provision of technical assistance to the MOHP, Ministry of Finance and other key ministries in order to improve budget formulation and allocation practices and, more generally, to strengthen health policy capacity; and the support to these institutions in their efforts to formulate a health insurance policy.

39. Component 2 is supporting component 1 and its results as it will put the focus on technical support in various dimensions of health system strengthening such as reinforcing human resources skills both at the clinical and managerial level, hence influencing quality. It will also provide opportunities to improve data collection and thus reinforcing the ability of policy development to be based on reliable data. Finally, the technical work and various interventions will strengthen the capacity of the Government to respond to and better define more equitable policies and interventions, hence addressing the inequeties across the system.

Sub-component 2.1: Introducing fee-waivers for the poor and fee exemptions for selected services – Total costs including contingencies US$4.5 million (of which IDA = US$.38 million, HRITF = US$.38 million and Government = US$3.75 million) 40. This sub-component will include the following activities:

a) The project will collaborate with experts from the Social Protection Program to

develop and implement instruments and procedures for the identification of the eligible groups (through community-based targeting). These citizens will benefit from improved financial access to health services through enrollment into a fee-waiver program for PBF-Health Sub-projects.

b) The project will also support the government in the development of criteria to determine which health services will be free for all citizens irrespective of socioeconomic status. Currently, the government has adopted exemptions for some medicines to treat high-prevalence infectious diseases, such as malaria and HIV/AIDS. The project will review the feasibility of this policy and may include other medicines and services such as preventive services for mothers and children. Finally, the project will also support the development and evaluation of pilot programs to test alternative waiver and exemption mechanisms (for example, via the Impact Evaluation).

41. Budget formulation. As already noted above, a preliminary review of budget allocations by the MOHP to the departments suggests that certain inequalities would be overcome if the MOHP adopted an explicit budget allocation formula. An allocation formula or criterion could consider the department’s population, the per capita cost of the minimum and complementary benefit packages, the degree of remoteness, poverty, and other variables. The project will support the assessment of resource allocation, and carry out a fiscal space analysis.

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Sub-Component 2.2: Capacity building in health policy and management – Total costs including contingencies US$3.5 million (of which IDA = US$.29 million, HRITF = US$.29 million and Government = US$2.90 million)

42. Technical support in the area of health insurance policy. The government of ROC has embarked on the path to reach UHC through health insurance. The Project will provide technical assistance to the government of ROC to further refine the health insurance draft law, discuss the feasibility of such a reform and examine the different options and develop a timeline for implementation. Project activities in this sub-component will include:

a) Providing technical assistance to the government of ROC to discuss the feasibility, content, and timing of a UHC law. With this aim, the project will commission a document that will summarize the experience of other developing countries with similar income and development levels and identify the crucial or essential institutional, financial and other elements for the development of a UHC law. The document will outline the enabling factors needed to enact such a law and identify a way forward. The starting point for this review will be the work already underway in ROC on the health insurance initiatives of Ghana and Rwanda.

b) Conducting policy workshops with government to discuss the findings and recommendations from the above review, with the aim of formulating a national consensus about the path to UHC. Participants in these workshops will include staff from the MOHP, Ministry of Finance, national experts, experts from reference countries, and members of parliament dealing with health laws.

c) Carrying out a feasibility study of health insurance schemes which would present the government with a series of options to be piloted at a later stage.

43. Capacity building in health policy and management. The pervasive lack of knowledge regarding health policy concepts, management skills, and regional and global best practices limits government’s ability to strengthen its health system. Along with the appropriate counterpart endorsement and partnerships, the project will:

a) Develop or adapt training materials in health policy and management, using as a

starting point those currently available from the World Bank Institute’s Flagship Program for Health System Strengthening. The training would focus on: priority setting in the health sector; development and costing of health benefits packages; methods for the targeting of government health subsidies; provider payment methods; results-based financing; and other topics that the government may identify. Finally, develop and implement a five-year training program for policymakers, and health managers, from the central and regional levels

b) Commission national case studies that reflect the local context to use as complementary training materials.

c) Strengthen existing capacity for research, analytical work, institutional strengthening of national institutions such as the statistic bureau, the planning department and other government entities will be done during the project period.

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Sub-component 2.3: Health Sector Monitoring and Evaluation (M&E) Strengthening— Total costs including contingencies US$4.5 million (of which IDA = US$.38 million, HRITF = US$.38 million and Government = US$3.75 million) 44. The insufficient capacity of ROCs health information system leads to inadequate monitoring and evaluation (M&E) of health sector performance and therefore an inability to use data for decision making. Several activities will be undertaken to strengthenthe monitoring and evaluation (“M&E) mechanisms in the health sector, in particular: (i) reviewing and updating the M&E framework and development plan; (ii) strengthening the M&E departments in the Ministry of Health and Population; (iii) undertaking a national health facility mapping exercise with a view to developing a master facility list including comprehensive data on health facilities; (iv) improving the health management information system; (v) developing and implementing an integrated diseases surveillance and response system; (vi) carrying out of various health facility surveys designed to assess the quality of health care; (vii) carrying out of various household surveys designed to assess the health system and its overall impact; (viii) implementing an appropriate ICT solutions program (a PBF web-enabled application); and (ix) carrying out of an impact evaluation).

45. Information and Communication Technology (ICT): the project will use a web-application (Open RBF: http://openrbf.org/) to manage the public front-end, and the back-end strategic purchasing. These open-source based solutions are driving the current two scaled-up PBF approaches (Rwanda; Burundi) and are used in an increasing number of PBF pilots in Africa and Central and South-East Asia. These ICT solutions also enable conditional cash transfer or voucher programs to be managed in an integrated manner, alongside the PBF program.12 The project will work closely with the HMIS department, and assist in the introduction of the new DHIS-2 software. The PBF web-enabled application will be linked to the DHIS-2 software and it will be managed through the HMIS unit. The ICT solution is part of the system of intense monitoring and evaluation for PBF results. Verified and purchased results including the results for the health administration will be visible on the public website whereas the raw data will be downloadable from the website. Benchmarking both the quantity and quality of health facilities and the public health administration will lead to a powerful tool to employ results monitoring and better governance. Introducing an ICT sub-component to the project to build the capacity of the MOHP will allow the health facilities to systematically keep track of funding and payments, record data, and use this data at both the facility and central level to make informed management and policy decisions to improve the health system of ROC.

46. An Impact Evaluation (IE) financed by a separate (Bank executed TF) HRITF will be embedded in the phased scaling-up of PBF: The HRITF will fund an Impact Evaluation (US$1.5 million), which will naturally fit into the phased scaling-up of PBF. The Impact Evaluation (see Annex 9) has a specific focus on the role of PBF, in combination with various demand-side interventions such as households visits for improved health-seeking behavior and targeting of the poor for improved financial access to a package of essential health services (links will be made with the LISUNGI project). The Impact Evaluation design was finalized and validated during the project appraisal mission in October 2013. 12 For an example of the application, see the one for Nigeria: http://nphcda.thenewtechs.com/

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B. Project Financing

47. The lending instrument will be an Investment Project Financing (IPF), financed under an IDA credit of US$10 million equivalent, an HRITF grant of US$10 million and US$100 million in counterpart funding from the Government of the Republic of Congo. The Bank and HRITF support are planned for five years (2014-2019). The proposed budget breakdown for the project is the following:

Project Cost By Component and/or Activity

US$ million

IDA (8%)

HRITF(8%)

Government (84%)

TOTAL

Component 1: Improvement of utilization and quality of health services at health facilities through PBF

8.60 8.60 90.30 107.50

Component 2: Strengthening Health Financing and Health Policy Capabilities

1.40 1.40 9.70 12.50

TOTAL 10.00 10.00 100.00 120.00 Note: Disbursements for all project activities will be made against two categories 1) for PBF expenses; and 2) for good, consultant services, non-consultant services, operational costs, and training.

C. Lessons Learned and Reflected in the Project Design

48. Lessons learned from the implementation of the past projects such as the HIV/AIDS project, and the on-going PDSS are taken into consideration in this project. Additionally the project design has also taken into account the experiences of other countries implementing similar projects.

49. Strengthening management capacity and promoting innovation are essential to achieving results in low-capacity environments. Given that ROC is a post-conflict country, the overall project management capacity was weak at the outset of the project. The recruitment of dedicated staff at central and regional levels, the sub-contracting of specific technical and managerial functions to appropriate agencies and non governmental organizations (NGOs), and the focused investment in capacity-building over the initial years of project implementation resulted in increased capacity at all levels. These lessons will be taken into account in the design of the proposed new project and will ensure that those responsible for planning, managing, and delivering services will be fully equip to perform their functions.

50. The following are lessons learned from the current PDSS project, they focus on both the experience of PBF and the experience to date of navigating the internal government structure in ROC. These lessons were derived from the design and implementation of both Bank and non-Bank operations in Africa. PBF leads to:

a) Improving the alignment between resources and maternal and child health priorities

by purchasing priority service delivery indicators at higher rates;

17

b) Improving the quality of health services by purchasing services conditional on quality;

c) Creating incentives for health facility managers and health workers to expand the coverage of essential public health interventions and improve their quality by linking facility payments to service delivery and quality indicators, and offering health workers bonuses that are linked to facility performance;

d) Improving governance through better verification and oversight of performance and providing incentives for good performance by involving the communities for verification of the health facility quality, and by involving civil society in assessing health service delivery results as well as by publishing results on a public website;

e) Reducing financial barriers to access quality health services by the poorest; and

f) Enhancing the functioning of the public health administration at all levels.

51. The success of PBF has also been well documented outside of ROC. Experience indicates that PBF approaches can be successful in rapidly increasing the use of cost-effective health interventions. Studies of PBF in Cambodia, Burundi, Haiti, and Afghanistan and a randomized controlled study in Rwanda have demonstrated its effectiveness. There are promising indications from a number of countries in Sub-Saharan Africa that suggest that PBF may be a useful approach to address the types of challenges evident in ROC. The Rwandan experience with PBF has attracted considerable interest and has had promising results in terms of increasing the proportion of staff in public sector facilities, increasing financing to the district level, and improving the coverage of key maternal and child health services. Neighboring Burundi has also - albeit more recently - implemented a PBF program that is similar to the one planned in ROC. For instance, since PBF has been implemented, facilities in Burundi are more likely to have the full complement of skilled staff, increasing from 37 percent in 2006 to 71 percent in 2010. Coverage of important health services such as skilled birth attendance has increased from 57 percent in 2006 to 82 percent in 2010, while contraceptive prevalence - often slower to change - has increased from 9 to 16 percent. 52. Besides providing an obvious performance-based motivation for health workers, PBF has a number of other advantages: (i) it gives a clear signal to health workers regarding the priorities of the government and ensures that facilities maintain a focus on preventive and pro-poor interventions; (ii) it ensures that projects focus on producing tangible results and on strengthening M&E systems; and (iii) it decentralizes decision making to managers who are much closer to the community. 53. In terms of usage of in-country systems, PDSS is one of the few projects being fully implemented by the Ministry of Health. Despite initial difficulties, it became apparent that building the capacity of all stakeholders is essential in ensuring buy-in at all levels for the project. Furthermore, ensuring that roles and responsibilities within the various units and departments in MOHP are well defined is essential in engaging all those involved in the project execution. Secondly, recognizing the complexity of Bank’s fiduciary and operational procedures, it is essential to provide local technical support from the outset to ensure that activities are not delayed. Finally, it is unrealistic to have the Minister as the signatory on contracts as they are

18

often occupied by official business thus leading to delays in project implementation. It is essential to have an autonomous unit in charge of the project that is empowered to execute an implementation plan/project plan that has been endorsed by the Minister and other key senior government officials. IV. IMPLEMENTATION

A. Institutional and Implementation Arrangements

54. The Ministry of Health and Population will implement the project through the Technical PBF Unit (CT-PBF). Project execution will take place at all levels (from the health facility to the central one) of the health system. The CT-PBF will be placed under the Director of the Cabinet (DC), with technical support from the relevant MOHP directorates. The CT-PBF is staffed by a multidisciplinary team including: a Project Coordinator (civil servant), a M&E specialist, a financial management specialist, an accountant, a procurement specialist, a health financing specialist, a public health specialist, an administrative assistant, and two support personnel. Others will be recruited on as needed. Members of the CT-PBF will possess the skills and experience needed for implementing the project.

55. Additional staff will be hired such as NGO/CBO specialists (who monitor the performance of health NGOs and will be awarded contracts to implement community-based projects). The CT-PBF shall be responsible for ensuring prompt and efficient day to day coordination, implementation and communication of Project activities and results, including: (i) preparing annual work plans and budgets for onward transmission to the National PNDS Steering Committee; (ii) carrying out all of the disbursements and any procurement related to the project in accordance with the Bank approved procedures; (iii) preparing and consolidating periodic progress reports; (iv) monitoring and evaluation of Project activities; (v) liaising with other stakeholders on issues related to Project implementation; (vi) providing administrative support to implementing agencies, all in accordance with the Project Implementation Manual; and (vii); serving as the fund holder, managing the operational accounts and transferring money to the health centers and withdrawing money as needed. The Project Coordinator, responsible for signing of the countract and all aspects of project implementation, will ensure efficient implementation of the various project components, to be carried out in collaboration with the respective technical units within the MOHP.

56. The CT-PBF will respond to the National PNDS13 Steering Committee in place for coordinating and implementing the National Health Sector Strategy (PNDS Comité de Pilotage). The National PNDS Steering Committee is chaired by Minister of Health and Populaton and includes representatives from key directorates of the MOHP, the Ministry of Planning and Economy, the Ministry of Environment, the Ministry of Finance, and representatives from the donor community. The National PNDS Steering Committee will oversee the implementation of PBF, review the annual PDSS II program and approve the annual work plan and budget, as well ensure harmonization between the implementation of the PNDS

13 PNDS: Plan National de Développement de la Santé is the Ministry’s National Health Strategy for the next 5 year. A PNDS national steering committee is already in place and hence it was agreed with the Government that the same steering committee would oversea the implementation of the PDSS II project.

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and the PDSS II. It will also provide guidance to the CT-PBF, and generate policy direction for the institutionalization of PBF in ROC.

57. Each quarter, the CT-PBF unit will be assessed through a performance-framework by a designated committee consisting of development partners. This performance framework will contain indicators related to (i) timely processing and execution of the PBF payment orders for health facilities and health administration; (ii) timeliness and management of the national PBF steering committee meetings; (iii) maintenance of the PBF web-application front and back-end; (iv) technical support to the ACV related to contract management, verification activities and strategic purchasing; (v) timely and correct application of the performance framework for certified drug distributors and the DDS; (vi) capacity building and coordination of the overall PDSS II; (v) timely and correct application of the performance framework of the certified drug distributors and the DDS; and (vi) capacity building and coordination. 58. The project policies and procedures will be incorporated in an implementation manual, which will be adopted by the MOHP. It will be complemented by a PBF user manual. The CT-PBF and the Bank will ensure that the PBF manual is consistent with the overall implementation manual. A more detailed description of the implementing arrangements is presented in Annex 3.

Technical

responsibility Fiduciary responsibility


1.1. Performance payments to health facilities

DGS/PBF unit (MOHP) DRF (MOHP)/ PBF unit

1.2 Governance, purchasing, coaching and strengthening health administration through Performance-Based Financing


Component 2: Strengthening Health Financing and Health Policy Capabilities 2.1 Introducing fee-waivers for the poor and fee exemptions for selected services

DEP/DGS/PBF unit DRF (MOHP)/ PBF unit

2.2 Capacity building in health policy and management


2.3 Health Sector Monitoring and Evaluation (M&E)

HMIS unit / PBF unit DRF (MOHP)/ PBF unit

B. Results Monitoring and Evaluation

59. The Results Framework focuses on accountability for results—it moves beyond the usual tracking of inputs and outputs and places a strong emphasis on intermediate outcomes. When possible, the proposed results framework uses existing indicators and data to measure the progress of both the project and its contribution to the overall national program; this

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will benefit the program in two ways, increase efficiency and strengthen existing data collection mechanisms. For example, routine monthly and quarterly data collected from the ROC’s HMIS will be aggregated for the project’s annual indicators to reinforce the national system and avoid creating a parallel structure. The project monitoring system will include (i) identification and consolidation of M&E indicators; (ii) training and capacity building initiatives at the national, regional, and local levels ; (iii) standardized methods and tools to facilitate systematic collection, and sharing of information; (iv) an independent review by external technical consultants; and (v) annual program evaluations and strategic planning exercises for each component.

60. The mid-term review (MTR) will assess the project’s performance, intermediate results, and outcomes. The MTR will be conducted no later than 30 months after effectiveness. In combination with the MTR, an independent assessment will be conducted to ensure that all processes (targeting, registration and payments) function as planned. 61. As discussed earlier in Component 2, rigorous monitoring based on the monitoring and evaluation (M&E) plan will enable the Government (and all partners) to monitor progress as well as the process evaluation of the project. Monitoring and process evaluation will occur at each stage of project implementation, in order to identify any issues that arise and address them promptly. During project implementation a qualitative beneficiary assessment will be conducted to collect feedback from participants about the project implementation and to elicit their perceptions of the project’s impact. Short beneficiary surveys and spot checks will gather vital information on program performance, targeting and payment. The project aims to have one process evaluation a year, and one spot-check evaluation a year to identify issues with the program and make timely modifications as necessary . 62. The results of the PBF component of the project will be assessed through a full Impact Evaluation (IE). The policy objectives of the Impact Evaluation are to (i) identify the impact of PBF on maternal and child health service coverage and quality, (ii) identify key factors responsible for this impact, and (iii) assess the cost-effectiveness of PBF as a strategy to improve coverage and quality. In doing so, we expect that the results from the Impact Evaluation will be useful to fine tune the design of the national PBF policy in ROC and will also contribute to the larger body of knowledge on PBF.

C. Sustainability 63. Technical sustainability will be ensured by capacity building and knowledge transfer activities throughout the project. For Component 1, capacity-building efforts at all levels of the health sector will be coordinated and implemented by the CT-PBF. Capacity in the CT-PBF will be created during the preparatory phase of the project through trainings and on the job coaching. A training of trainers will create a pool of knowledgeable PBF trainers who will then train additional trainers using cascade training. Local civil society will also be selected, and trained to act as purchasing and verification agents. This capacity transfer and training program will continue throughout the project and will decline towards the end of the project cycle when capacity has been sufficiently built.

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64. Financial sustainability of PBF can be reasonably achieved given the limited cost of this mechanism and the fact that the majority of the funding is provided by the government (84 percent). The project will help improve the efficiency of health spending by improving the outcomes obtained from the current total health expenditure of US$39 per capita. By spending less than US$5 per capita, per year, per beneficiary, the cost is likely to be affordable and sustainable in the long term. By designing a linkage with the social protection project , having a focus on financing of waivers for the poor, and including a rigorous Impact Evaluation, the program is expected to thoroughly evaluate the PBF experience in ROC and to mainistream this approach in ROC’s public health spending. Additionally by integrating an ongoing policy dialogue on exemptions and waivers, HMIS strengthening, human resources for health reform, health financing reform, and enhancing autonomy for decentralized government funding, the project is expected to institutionalize these PBF reforms. V. KEY RISKS AND MITIGATION MEASURES

A. Risk Ratings Summary Table

Risk Category Rating

Stakeholder Risk Moderate

Implementing Agency Risk

- Capacity Substantial

- Governance Substantial

Project Risk

- Design Substantial

- Social and Environmental Substantial

- Program and Donor Moderate

- Delivery Monitoring and Sustainability Moderate

Overall Implementation Risk Substantial

B. Overall Risk Rating Explanation 65. The overall risk can be qualified as ‘substantial’ given the weak institutional capacity and governance that characterizes ROC. However, the government is very engaged and its commitment to this operation is very high. The government pledged US$100 million in counterpart funding and has demonstrated throughout the project cycle from project identification through preparation, a strong willingness to reform and transform their health system to ensure that ROC achieves their MDG targets (especially MDG 4 and 5) or at least makes significant headway by 2015. It has also indicated its commitment to implementing Universal Health Coverage in the next 5-7 years. The government has also garthered the support of the external partners, including WHO, UNICEF, and UNFPA, who are keen to support the

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project PDO, and components, and who have agreed to provide technical and potentially financial support for the project. 66. To ensure stronger governance of the project, training in fiduciary and procurement guidelines as well as management skills will be introduced during project preparation and implementation. Furthermore, performance frameworks introduced at each level (central to health facility level) will strengthen the stewardship and the governance aspects of the project. Additionally, by effectiveness the World Bank team along with the Government team will develop and implement a series of technical skills building workshops to reinforce the counterpart’s ability to manage and coordinate the project and ensure that all health facilities and managers at the DDS and CSS level are ready for project effectiveness. Finally, given that the Ministry of Health and Population has adopted PBF as a national financing policy, this will facilitate the institutionalization and sustainability of this approach and ensure synergy for the project. The project design recognizes these weaknesses and has addressed them by involving experienced national and international expertise. 67. Furthermore, the risk of having health workers manipulating results indicators is significantly reduced by ex-ante verification by NGOs, and ex-post verification by the external evaluation agency. Experience from other countries shows that this can be successfully mitigated through gradual scale-up, technical assistance, and training. These have already begun and will continue throughout project implementation. The implementing agency, design, and delivery quality risks are rated as Moderate. 68. Finally, the country has experience with a home-grown PBF approach and this new project builds on the lessons learned. The experience is helping the project team to better understand the potential of this approach in ROC, to strengthen the quantity and quality aspects of service delivery and better frame the issue of access, especially among the poor. VI. APPRAISAL SUMMARY

A. Economic and Financial Analysis

69. The project will be comprised of two components, the first accounting for the majority of project resources (over 75 percent), and the second accounting for the remaining funds. Component 1, “Improvement of access and quality of health services at health facilities through performance-based financing (PBF),” will finance and implement a performance based financing (PBF) provider payment system in several regions of the country, covering 86 percent of the population. It will use project resources to design and implement a PBF system to pay public providers to deliver a higher volume of improved quality maternal and child health services, both curative and preventive, including exemptions for the poorest.

70. Component 2 “ Strengthening Health Financing and Health Policy Capabilities”, will finance the following interventions: adoption of a system of waivers and exemptions in government health facilities, improvements in health budget formulation and allocation criteria, and assessment of health insurance development policies. It will also focus on improving the National Health Information System.

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71. The economic evaluation will seek to quantify the economic costs and benefits of components 1 and 2. It is expected that Component 1 will result in a higher volume of improved quality curative and preventive services for mothers and children. The economic evaluation outlines the costs incurred by the project under sub-component 1.1 (payment of bonuses to health care providers) with the benefits that result from the provision of additional health services. The bonuses are expected to motivate providers to deliver more and better quality services in health centers and hospitals. 72. Each additional unit of service delivered, whether it is preventive or curative, will lead to an improvement in the patient’s health status. In the economic evaluation, this improvement is measured in Disability Adjusted Life Years (DALYs), a common measure of effectiveness of health projects (Jamison, Breman et al. 2006). Gaining one DALY for a person is similar to gaining one year of healthy life.

73. In the evaluation, the cost-effectiveness ratio is obtained by dividing the cost of the bonus paid by the project for an additional unit of service (for example, one prenatal visit or one curative consultation to a child) by its effectiveness. The cost-effectiveness ratio is measured in dollars per DALY. The cost-effectiveness ratio can be seen as the cost that is required to improve by one healthy year the health of a beneficiary. Gains in healthy life result from a reduction in premature mortality and disability.

74. Preliminary results from the economic evaluation indicate that the project is highly cost-effective. The total cost of the entire sub-component 1.1 is XAF 42,499 million (US$87.5 million). The overall cost-effectiveness ratio of the services financed through the project in health centers and hospitals is estimated at US$70 per DALY. This is a relatively high cost-effectiveness ratio. In other words, allocating this volume of project resources to performance bonuses for health care providers yields good value for money. To put this figure in perspective, it can be roughly interpreted as follows: saving a year of health life for a project beneficiary costs US$70. This is a mere 2 percent of the annual per capita Gross Domestic Product in ROC, equal to US$3,154.14 75. According to ROC’s National Health Accounts study (Ministère de la Santé et de la Population 2013) in 2010, households financed approximately 37 percent of all health care costs in the country through out-of-pocket (OOP) payments. By lowering the user fees for patients in government health facilities, the project will promote greater access to health services and will also help to alleviate poverty. Preliminary results from the project’s financial evaluation suggest that performance bonuses will almost equal current OOP payments by poor households and they should cover a substantial portion of OOP payments for nonpoor households.

B. Technical 76. The project supports a package of basic and complementary health services, predominantly maternal and child health interventions aimed principally at improving health related MDGs in the 7 selected Departments. The approach of investing in maternal 14 Amount in current dollars, not adjusted by purchasing power parity.

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and child health interventions is aligned with the Plan National de Development de la Santé (PNDS), which outlines the Republic of Congo’s health priorities over the coming 3 years (2013-2016). Additionally, ROC is very focused on meeting its health related MDG targets MDGs 1, 4, 5 and 6 and especially MDGs 4 and 5. Which target under 5 mortality and maternal mortality respectively. This project will reinforce the government’s priorities and aim to strengthen the health system and focus on maternal and child health interventions through PBF.

77. The design of PBF arrangements in ROC is based on the best practices and experiential knowledge gained in other successful PBF projects. For example, external entities (such as community-based organizations) will be strongly involved in promoting and monitoring PBF results. Similarly, the mechanism to determine PBF credits is a “fee-for-service conditional on quality” system, which has been applied with successful results in other PBF projects in Rwanda, Burundi, DRC, Zambia, Zimbabwe, Nigeria, Benin and Chad. Such a system ensures that (i) the PBF mechanism is clear and can easily be understood by health workers and communities and (ii) the increase in the quantity of care does not adversely affect quality.

78. The procurement method that will be used to recruit the ACVs is “quality-and cost based selection”.

C. Financial Management 79. As part of the Congo Health System Strengthening Project-II preparation, a financial management assessment of the implementing unit within the Ministry of Health and Population (MOHP) has been carried out. The objective of the assessment is to determine: (a) whether this unit has adequate financial management arrangements to ensure that project funds will be used for purposes intended in an efficient and economical way; (b) project financial reports will be prepared in an accurate, reliable and timely manner; and (c) the project’s assets will be safeguarded. The financial management assessment (FMA) was carried out in accordance with the Financial Management Practices Manual issued by the Financial Management Sector Board on November 3, 2005, as revised in 2011. In this regard, a review of the financial management existing system (budgeting, staffing, financial accounting, financial reporting, funds flow and disbursements, internal and external audit arrangements) at the MOHP’s Projects’ Coordination Unit level has been conducted.

80. This unit is currently implementing the Health Development Project-I financed by the World Bank, the financial management staff includes a Financial and Administrative Expert who is responsible for financial and administrative matters and an accountant. They have been trained in the use of World Bank procedures as well as the accounting software namely TOMPRO over the last years of project implementation. Unaudited Interim Financial Reports (IFRs) for the PDSS-I are submitted on time, reviewed and found to be satisfactory. The external auditors issued a clean audit report for the year ending December, 2012 and the management letter from the external auditors did not raise any major issues; there are no overdue audit reports and interim financial reports from this entity.

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81. The project maintains proper books of accounts which include a cash book, ledgers, journal vouchers and a contract register. They prepare the necessary records and books of accounts which adequately identify, in accordance with accepted international accounting standards and practices, the goods and services financed out of the proceeds of the Credit and Grant. It is expected that the accounting system will be used for the implementation of this project. The assessment concluded that, the overall residual FM risk is substantial due to Country’s weak capacity context coupled with the project design.

82. The overall project funding will consist of US$120 million (US$100 million counterpart funds provided by RoC, US$10 million from IDA and US$10 HRITF). The funds will be managed through two (2) bank accounts to be opened and maintained by CT-PBF in a commercial bank acceptable to IDA as follow: (i) a pooled Designated Account (DA) denominated in CFAF to receive IDA and TF advances, and to pay for project expenditures eligible for IDA and HRITF financing; (ii) a Project Counterpart Funds Account in CFAF to receive counterpart deposits and replenishments, and to record payments eligible for ROC resources (see Annex 3 for further details on assessment, financial management processes, and risk mitigation activities).

D. Procurement 83. As part of the Congo Health Systems Strengthening Project-II preparation, an assessment of the existing Procurement Unit capacity to implement procurement activities for the project was carried out in May 2013. The assessment reviewed the internal arrangements for handling procurement, the organisational structure for implementing the project, and the capacity of staff responsible for procurement activities under the proposed project. The assessment also reviewed the interaction between the project staff responsible for procurement and the new structures wich implemented the new procurement code. Finally, it was agreed that the following procurement, consulting, and anti-corruption guidelines will apply: (i) “Guidelines on Preventing and Combating Fraud and Corruption in Projects Financed by IBRD Loans and IDA Credits and Grants”, dated October 15, 2006 and revised in January 2011”; (II) “Guidelines: Selection and Employment of Consultants under IBRD Loans and IDA Credits and Grants by World Bank Borrowers” dated January 2011”; and (iii) “Guidelines: Procurement of Goods, Works and Non-consulting Services under IBRD Loans and IDA Credits and Grants by World Bank Borrowers” dated January 2011”.

84. Procurement Implementation arrangement. The existing procurement capacity under the line ministry procurement unit of MoHP (Cellule de gestion des Marchés Publics du Ministère de la Santé et Population) will be used to handle the fiduciary functions. Procurement performance of the unit has been moderately satisfactory for the last two years.

85. The risk factors for procurement performance include the country context and the low procurement capacity of the MoHP. This ministry will be in charge of project implementation with the support and technical assistance of experts of the existing coordination unit. In terms of the sector and country context, the country procurement issue paper (CPIP) and the experience of other IDA- and Internationally-funded projects (IFI) indicate that procurement on the project is likely to involve the following risks:

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a) A weak governance environment, weaknesses in accountability arrangements, and an

overall lack of transparency in conducting procurement processes creates significant risks of corruption, collusion and fraud;

b) The administrative system as it operates in practice creates opportunities for informal interference in the procurement process by senior officials – creating opportunities for waste, mismanagement, nepotism, corruption, collusion and fraud;

c) Government officials are likely to be involved in project procurement through tender committees and the national control system ensuring that the rules are respected and able to handle complaints from bidders may not be familiar with procurement procedures; and

d) The control and regulatory system does not fully and totally operate in an independent manner.

86. The overall project risk for procurement is substantial before risk mitigation. (Annex 3 for further details on assessment, procurement processes, and risk mitigation activities).

C. Social (including Safeguards)

87. The project is expected to have a positive social impact by improving access to health care services for the poorest households. Component 1 (through the payment for performance) will provide incentives for health facilities to reduce staff absenteeism and to improve staff responsiveness with patients. As a result, health facilities with PBF contracts will provide more and better quality care for marginalized populations. The project will also build on synergies with the LISUNGI project which is providing a Conditional Cash Transfer for a targeted group of poor and elderly citizens in ROC. The project will collaborate closely with the LISUNGI project to provide quality health services to this population.

88. The project will be implemented in the area where indigenous peoples (IPs) are located. While the project will not as such negatively affect IPs, OP/BP 4.10 policy is triggered to ensure that IPs will benefit from the project. The expected impacts are positive as the IPs do not have access to quality care and hence the project will ensure that free quality care is provided to them to ensure better health outcomes.15 The IPPF was disclosed in-country and through the World Bank’s Infoshop on November 13, 2013. 89. The project will have a positive impact on gender in ROC. Given that the project’s main objectives are to improve maternal and child health in target areas, improving women’s health is an essential component of the intervention. Particular attention will also be given to ensuring active participation of women in the health center committees (COSAs), and as

15 OP/BP 10.00, paragraph 11 allows for flexibility that can be utilized in cases where the “Borrower/beneficiary is deemed by the Bank to: (i) be in urgent need of assistance because of a natural or man-made disaster or conflict; or (ii) experience capacity constraints because of fragility or specific vulnerabilities (including for small states)." This flexibility was used under the project to defer the disclosure of safeguard instruments until the negotiations stage.

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community client satisfaction surveyors during the ex-post evaluations. The project is expected to have a positive impact not only on pregnant women but on all women, as PBF will improve the quality of care for the identified package of health services for the general population.

90. This project builds on continuing consultation and communication with the government. The government and Bank have been actively engage in dialogue over the current PDSS project in ROC. This project has allowed the Bank team to conduct an ongoing dialogue with the government, at both the national and local levels; development partners are also active in this dialogue. The components of the project build on lessons learned from the ongoing investment.

D. Environment (including Safeguards) 91. The project has been assigned environmental category C. The project will contribute to enhancing the overall health environment of the country. Potential adverse environmental impacts of this project are considered minor. 92. IDA supervision will focus on (i) providing regular implementation support, (ii) carrying out field reviews of safeguards implementation, and (iii) monitoring safeguards implementation based on periodic progress reports. IDA supervision will be carried out by field-based Bank technical staff and complemented by specialist consultants not only during regular biannual supervision missions but also during interim technical safeguards missions that will respond to emerging issues.

Two safeguard policies were triggered, as follows:

Safeguard Policies Triggered by the Project Yes No Environmental Assessment (OP/BP 4.01) [X] [ ] Natural Habitats (OP/BP 4.04) [] [X] Pest Management (OP 4.09) [ ] [] Physical Cultural Resources (OP/BP 4.11) [] [X] Involuntary Resettlement (OP/BP 4.12) [] [ ] 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]

* By supporting the proposed project, the Bank does not intend to prejudice the final determination of the parties' claims on the disputed areas. 93. OP/BP 4.01 Environmental Assessment: This policy is triggered; the project has minimal environmental impacts that shall be governed by national and local laws and procedures. An existing medical waste management plan prepared for the ongoing Health System Strengthening Project (P106851) Bank financed project was disclosed through the World Bank Infoshop on October 9, 2013 and in country on November 7, 2013.

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94. OP/BP 4.10 Indigenous People (IP): This policy is triggered to ensure that indigenous peoples will benefit from social outputs of the project. This project does not expect to impact negatively the IP. An Indigenous Peoples Planning Framework (IPPF) was disclosed in country and at the InfoShop on November 13, 2013. Furthermore, if any Health Subproject would, require the preparation of an Indegenous People Plan (IPP), the MoHP will ensure that such IPP is prepared and furnished to the WB for review and approval, and is disclosed as required by the IPPF.

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ANNEX 1: RESULTS FRAMEWORK AND MONITORING

.

Republic of Congo

Project Name: Health System Strengthening Project II (PDSS II)

.

Results Framework

.

Project Development Objectives

PDO Statement

The objective of the Project is to increase utilization and quality of maternal and child health services in targeted areas..

These results are at Project Level

.

Project Development Objective Indicators

Cumulative Target Values Data Source/

Responsibility for

Indicator Name

Core Unit of Measure

Baseline16

YR1 YR2 YR3 YR4 End

Target Frequency

Methodology

Data Collection

1. Children immunized 17(number)

Number 70,284 76,102 80,018 84,100 90,088 98,144 Quarterly HMIS/PBF database

MIHP/HMIS

2.Percentage of pregnant women having

Percentage TBD TBD

TBD

TBD

TBD

TBD Quarterly

HMIS/PBF database

MOHP/HMIS

16 Baseline indicators where labedled “TBD” will be determined at the time of the baseline survey expected to be done by June 2014. The targets will also be determined at that time. 17 The project will look at the number of fully immunized children under one which would be inclusive of BCG and DTP3.

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at least 3 antenatal care visits before delivery18

3. Percentage of children aged between 6 and 59 months receiving nutritional services

Percentage TBD

TBD

TBD

TBD

TBD

TBD

Quarterly HMIS/PBF database

MOHP/HMIS

4. New curative consultation per capita per year

Rate 0.20 0.25 0.30 .30 .35 .40 Quarterly HMIS and PBF Database

MOHP/HMIS

5. Average Score of the quality checklist19

Percentage TBD

+15

+25

+25

+30

+35

Quarterly PBF database

MOHP/CT-PBF/DDS/CSS

.

18 It is difficult to provide 4 ANC visits since most women do not come to the health center in the 1st trimester due to many reasons including cultural norms, stigma and lack of awareness of their pregnancy. 19 The quality check list is a comprehensive quality assessment of the quality in a health facility, including more than a hundred of items related to the following aspects: hygiene, drug availability, clinical care, equipment availability, drug management, financial management, laboratory, etc. Clinical audits are also part of the quality assessment.

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Intermediate Results Indicators

Cumulative Target Values Data Source/

Responsibility for

Indicator Name

Core Unit of Measure

Baseline YR1 YR2 YR3 YR4 End

Target Frequency

Methodology

Data Collection

6. Number of new and existing acceptors of modern contraceptive use20

Number TBD

TBD

TBD

TBD

TBD

TBD Quarterly

HMIS/PBF Database

MOHP/HMIS

7. Percentage of pregnant women who received two doses of IPT21

Percentage 15 18 22 25 28 32 Quarterly HMIS/PBF Database

MOHP/HMIS

8. Percentage of women counseled and tested for HIV

Percentage 22 24 26 28 30 32 Quarterly HMIS/PBF Database

MOHP/HMIS

9. Number of poor people benefiting from fee exemption mechanisms

Number TBD

TBD

TBD

TBD

TBD

TBD

Quarterly PBF Database

CT-PBF/CSS/DDS

20 Condoms use will not be used here as it is very difficult to verify. 21 Intermittent Prophylactic Treatment against Malaria.

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10. Health personnel receiving training (number)

Number TBD

TBD

TBD

TBD

TBD

TBD Quarterly

HMIS/PBF Database

MOHP/ HMIS

11. Number of Direct Beneficiaries, of which female22

Number TBD

TBD

TBD

TBD

TBD

TBD

Quarterly HMIS/PBF Database

MOHP/HMIS

.

22 Drawn from PBF database from services that are specifically used by women and for interventions of component 2 inclusive of women.

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ANNEX 2: DETAILED PROJECT DESCRIPTION

REPUBLIC OF CONGO


1. The project will test innovations initially in 7 out of the 12 Departments of ROC and will recommend scaling up to the remaining departments if the initial intervention is deemed successful. The project will comprise of the following components. Component 1: Improvement of utilization and quality of health services at health facilities through Performance-Based Financing (PBF) - Total costs including contingencies US$107.5 million (of which IDA = US$8.95 million, HRITF = US$8.95 million and Government = US$89.60 million) 2. A PBF approach (whereby PBF Grant Agreements will be signed with the health facilities and whereby PBF Grants will be paid based on results achieved) will be introduced throughout the entire health system covering health facilities, first level referral hospitals, and health administration at district (CSS), departmental (DDS) and select departments at central Ministry of Health and Population (MOHP) level. Local civil society organizations will be selected and trained to become contract management and verification agents. Grassroots organizations will be engaged to measure service use and client satisfaction and community health committees (COSAs) will be strengthened. As there is a considerable and growing private sector in ROC, Component 1 will also strengthen public-private engagements in the health sector via PBF whereby private for profit facilities will be contracted out for the provision of quality health services. Work with the private sector will be further developed in collaboration with IFC and will ensure that public-private partnership interventions to strengthen the health system will be integrated. 3. ROC has a short, albeit useful in-country experience with PBF and this experience will be informing the scaling-up. A PBF pilot has been implemented in three departments (Niari, Pool, and Plateaux) since January 2012. The pilot project is financed by the current Bank financed health project (PDDS). The international non-governmental organization CORDAID has been selected to implement this pilot project, using a private-purchaser approach. A separate agency, EPOS assisted by Brandeis University has been recruited to document the impact of the PBF intervention, and also to monitor the effectiveness of the project implementation. The project is designed based on current best practice, and implemented by an experienced team of international (Southern) and national PBF experts. Contracts have been signed with 3 health department units; 9 district health teams, 7 hospitals and 73 health centers. Due to some delays related to contract approval, the pilot which had started in January 2012 was stopped in July-September 2012 and restarted in October 2012. During the first nine-months of operations (October 2012 - June 2013) key essential health services have started to increase significantly. Also, the quality of health services, and the performance of the health administration at district and departmental levels have improved noticeably.23

23 EPOS-Brandeis mid-term evaluation, April 2013, and also field observations.

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Table 1: Results for select services at the Health Center level (Oct 2012- March 2013) Absolute number of services

N° Service October to December 2012

January – March 2013

1 New curative consultations 16 460 25 342 2 Fully vaccinated children 1 889 2 970 3 Voluntary councelling and testing for HIV 490 751 4 PMTCT: pregnant mother tested 1045 1 186 5 Institutional delivery 1 509 1 765 6 Modern family planning method acceptor 201 262 7 Second to the fifth tetanus vaccination for a

pregnant woman 3 537 3 792

Table 2: Results for select services at the first referral hospital level (Oct 2012- March

2013) Absolute number of services

N° Service October to December 2012

January – March 2013

1 Outpatient consultation by a MD 587 970 2 Femme enceinte sous ARV 2 5 3 Major surgical procedure (ex CS) 151 239 4 Admission days 5,520 9,053

4. Component 1 will help set the foundation for Universal Health Coverage (UHC) by promoting the adoption of benefit packages at the ambulatory and hospital levels, developing a system of exemptions and waivers for health services, and adopting a provider payment system that promotes a greater number and better quality of services, and empowers communities to influence the performance of the health system. This component has two sub-components:

Subcomponent 1.1: Provision of PBF Grants to Health Services Providers for delivery of Health Subprojects (MPA and CPA), to women and children - Total costs including contingencies US$87.5 million (of which IDA = US$7.27 million, HRITF = US$7.27 million and Government = US$72.98 million) 5. For the Republic of Congo, the PBF approach has already been adapted and the following design and implementation elements are discussed below: (1) in-country experience with PBF; (2) design of a basic and complementary package of health services; (3) design of the quantified quality checklists; (4) institutional arrangements and governance; (5) inter-sectoral collaboration with social protection; (6) introduction of waivers for the poor; and (7) PBF output budget, costing and PBF approach. 6. Two benefit packages (or Health Sub-projects ) of health services have been designed in ROC for use in the government health system. They are the Minimum Package of Activities (MPA), which contains 23 preventive and curative primary health services to be

35

provided in government health centers, and the Complementary Package of Activities (CPA), with 18 services to be delivered in first level referral government hospitals (Cordaid Project). These benefit packages were designed during a technical meeting in Brazzaville in July 2013 for use in a PBF pilot initiative and are based on international best practice. The services selected provide a great potential for accelerating ROC’s achievements for the health related MDGs 1, 4, 5 and 6 and are based on the burden of disease for ROC.24 7. MPA- Minimum package of activities at the health center and community level consists of:

1. New curative consultation 2. New curative consultation – indigent (fee exemption) 3. Admission day 4. Admission day – indigent (fee exemption) 5. Minor surgery 6. Fully vaccinated child 7. Growth monitoring: child aged 0-11 months newly registered for growth monitoring 8. Growth monitoring : child aged 12-23 months seen for growth monitoring 9. Growth monitoring : child aged 25-59 months see for growth monitoring 10. Child 0-59 months treated for moderately severe malnutrition 11. Antenatal consultation (new and standard visit) 12. Prevention of mother to child transmission of HIV : pregnant woman tested for HIV 13. Antenatal care: second to the fifth tetanus toxoid vaccination 14. Antenatal care: second dose of prophylactic antimalarial 15. Post natal consultation 16. Institutional delivery 17. Family planning: new and recurrent user of modern family planning method (pills and

injection) 18. Referral for a severe condition arrived at the hospital 19. Home visit : (domestic waste disposal ; latrine ; insecticide treated bed net available;

access to clean water ; Family planning use – incl. Condom-, vaccination status ; nutritional status children)

20. HIV+ client under Co-trimoxazol prophylaxis 21. Voluntary counseling and testing for HIV 22. Acid fast bacilli positive pulmonary tuberculosis patient diagnosed 23. Acid fast bacilli positive pulmonary tuberculosis patient treated and cured

8. CPA- Complementary Package of Activities at the first level referral hospital include:

1. Outpatient consultation by a medical doctor 2. Outpatient consultation by a medical doctor of an indigent (fee exemption) 3. Admission day 4. Admission day – indigent (fee exemption)

24 According to the 2010 Global Burden of Disease studies, for the first ten conditions that cause the highest burden of disease, Congo ranks the worst (15th ranking) for eight conditions among its comparator countries. These conditions are HIV/AIDS, Malaria, Diarrheal diseases, Lower respiratory tract infections, Protein energy malnutrition, Road injuries, Congenital anomalies and Meningitis.

36

5. Referred patient arrived at the hospital and counter-verification arrived at the hospital 6. Major Surgery (defined list) 7. Institutional delivery - normal 8. Caesarean section 9. Institutional delivery - complicated 10. Client under anti-retroviral treatment seen six-monthly 11. Voluntary counseling and testing for HIV 12. Prevention of mother to child transmission of HIV :HIV+ pregnant client put under anti-

retroviral protocol 13. Prevention of mother to child transmission of HIV : newborn from an HIV+ mother put

under anti-retroviral protocol 14. Family planning: new and recurrent user of modern family planning method (pills and

injection) 15. Family planning: new user of an intrauterine device or implant 16. Family planning: bilateral tuba ligation and vasectomy 17. Acid fast bacilli positive pulmonary tuberculosis patient diagnosed 18. Acid fast bacilli positive pulmonary tuberculosis patient treated and cured

9. A quantified quality checklist will be designed for each level of the service package incorporating lessons learned during the pilot and taking into account international best practice. For each level, for health centers and hospitals, a quantified quality checklist will be designed. The checklists used in the PBF pilot will provide the foundation for these checklists they will also incorporate experience from other contexts on process oriented quality of care measures with increased weights given to process measures. They will also introduce measures related to rational prescribing of generic drugs, essential drug management and tracer drugs.

10. Intense results monitoring is the hallmark of the PBF approach; the results monitoring consists of a mix of ex-ante and ex-post verifications. Quarterly performance payments will be based on: (i) ex-ante verification of quantity (Agence de Contractualisation et Verification- ACV) and quality of health services (CSS) at health centers; (ii) ex-ante verification of quantity (ACV) and quality of health services (DDS) at hospitals; (iii) ex-ante verification by a third party (ACV) for DDS and drug regulatory authority/MOHP; (iv) ex-ante verification by the DDS for the CSS; (v) ex-ante verification by the PBF-unit for the certified drug distributors; and (vi) ex-ante verification by an ad-hoc committee consisting of development partners for the PBF-unit. Ex-post verification, that is, verification after payment has been made, will be carried out by the independent third party (ACVE) – through a protocol using random sampling- on the quantity of services; the quality of services; and the performance frameworks of the CSS, DDS, the MOHP units under contract and the certified drug distributors.

11. Intersectoral collaboration with a new Social Protection Program: The Social Protection Sector is supporting the preparation of the LISUNGI Safety Nets System Project in ROC (LISUNGI). LISUNGI will pilot active targeting of the poor using existing community mechanisms to identify beneficiaries for project subsidies and to stimulate access to health services. The LISUNGI project is planned to have a national poverty registration system (known as the Unified Registry) for enrollment into conditional cash transfer (CCT) programs linked to health and education behavior. There is large potential for complementarity and for economies

37

of scale. It is expected in the long term that this project will benefit from LISUNGI’s Unified Registry system for identification of the poor, who will in turn benefit from fee-exemptions for essential health services targeted by PBF.

12. PBF output budget, costing and PBF approach: A costing of the variable costs (excluding HR) of the basic and complementary package of health services was concluded at appraisal. Human Ressource studies will be conducted during project implementation that will inform the project on the actual take home income, expense patterns of health workers and which will shed light on their coping strategies. These costing and HR studies will help to inform the fee setting and the overall PBF budget. Based on an examination of similar contexts, taking into account the salary structure, and the objective to finance fee-exemptions for the poorest of the poor, it is estimated that an output budget of at the least US$5 per capita per year would be necessary.

a. The PBF approach is a fee-for-service with additional 25 percent maximum earnings based on the quality measure.

b. Geographic equity adjustments are also planned during project implementation, which offers the possibility to ring-fence regional output budgets, as well as health center and hospital output budgets (2/3 for health centers versus 1/3 for hospitals) and to set differential fees based on rural hardship criteria.

Subcomponent 1.2: PBF Capacity Development Subprojects focusing on Governance, purchasing, coaching and strengthening health administration - Total costs including contingencies US$20.0 million (of which IDA = US$1.68 million, HRITF = US$1.68 million and Government = US$16.68 million) 13. Contract management and verification: a purchasing arrangement will be created covering batches of 500,000 persons. An innovative strategy will be followed to build local capacity in PBF contract management and verification functions. Local civil society organizations (Agence de Contractualisation et Verification- ACV) will be selected through a contracting process. Their capacity for PBF contract management, verification, and counter-verification will be built through PBF experts housed in the PBF unit (CT-PBF) in the MOHP. These local organizations will be under a performance contract with the CT-PBF in which the timely and correct execution of their tasks will be measured and rewarded through a quarterly performance framework. See image below for the institutional arrangements:

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Graph 1: Institutional arrangements for ROC- PBF

14. Performance frameworks (or Capacity Building Grants) will also be introduced throughout the health system and will hold health administration units (HAU) accountable for services through incentive mechanisms. Internal performance frameworks contracts will clearly outline the expected performance of the different HAU vis-à-vis their roles in the health system and lead to successfully scaled up PBF approaches. The Performance frameworks are assessed quarterly through a mix of internal and external verifications before payment is made (ex-ante), and are randomly counter-verified (ex-post; after payment) using a third party agent to ensure reliability of the ex-ante performance assessments. A system of tested penalties will be instituted to discourage gaming. The determination of the fees associated with each service will described in the PBF manual. For the internal verification, the Health Verification Team will verify on a quarterly basis: (i) the quality and quantity of the Minimum Package of Activities and/or of the Complementary Package of Activities, respectively, delivered under a Health Subproject for which a PBF Grant is requested; and (ii) the performance of implementing agencies (including Health Administration Units) under the Performance Frameworks.

39

15. Verification and counter-verification of the DDS, ACV, CSS and drug regulatory authority/MOHP HMIS/MOHP department performance will occur each quarter. An external evaluation agency (Agence de Contre-Vérification Externe - ACVE) will assess the performance of the ACV, DDS, CSS, HMIS department/MOHP and of the drug regulatory authority/MOHP. This agency will be recruited under component 2. This ACVE will carry out each quarter, independent verifications of: (i) the delivery of the Minimum Package of Activities and/or of the Complementary Package of Activities, respectively, by HSPs under respective Health Subprojects, and (ii) the performance of implementing agencies (including Health Administration Units) under the Performance Frameworks. In addition, the ACV will carry out each quarter:

a) a verification of the performance of the HMIS and drug regulatory authority/MOHP; b) a counter-verification of the quantity of services through a lot quality assurance

sampling protocol with intense use of mobile phone technology and a community client satisfaction survey component;

c) counter-verification of a random sample of CSS and DDS performance assessments; d) counter-verify a random sample of health center quality checklists; and e) counter-verification of a random sample of hospital quality checklists. In the case of

discrepancies surpassing 5 percent score in any of the verified samples (whether quantity, quality or performance frameworks for the CSS), a significant penalty will be imposed on the performance earnings of the institution that reported this performance. The penalties for fraud will be clearly outlined in the various contracts and procedures and will be detailed in the PBF manual.

16. Communities will be empowered in their roles as co-managers of health services. This will be a two-way process with both interventions from the project (supply side) and community (demand side) perspectives. Communities will be informed through information campaigns as to what services to expect from the CIS and hospitals. Furthermore, communities will be pooled into assessing the quality of the health services provided.

a. On the supply side it will build the capacity of the beneficiaries at central and decentralized levels to coordinate government-community partnerships and strengthen community participation in the management and delivery of health services by enhancing effective synergies between packet of essential services (PSE) and other determinants of health (water, environmental sanitation, vector management). Part of the capacity building efforts include the creation of a community involvement cell at the Government level within the PBF project to coordinate, monitor, and evaluate the results of this community engagement.

b. On the demand side, it will focus on communities and citizens to enhance the effectiveness of the service delivery interventions and to strengthen the overall governance of the PBF program. The table below summarizes the different elements of the demand-side interventions.

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Enhancing the effectiveness of the service delivery model

Strengthen the governance of the PBF program

- Community participation in the design of the service delivery model: A community-based service delivery design process will increase the acceptability of the intervention. COSAs will play a role in this process

- Community-based targeting of the poorest of the poor

- Community Outreach programs: The relais communautaire (RC) are ideal partners to enhance the outreach of the service delivery model outside of the facility. RCs are community-based organizations.

- Empowerment citizen and patient to demand and exercise their rights: Patients will receive a “membership card” that will explain their bill of rights and a detailed description of the subsidized services and of their out-of-pocket costs.

- Information Campaign: Aimed at increasing the health related knowledge this element will use a multi-product and multi-channel information and communication campaign targeting the most vulnerable groups.

- Accountability and transparency functions: COSAs will play different check-and-balances roles in the reporting of financial and utilization data at the facility level

- Community based grievance and redress mechanisms: Communities can lead or support the design or implementation of these mechanisms at the facility level.

17. Health-seeking behavior studies to be conducted as part of the project will inform the design, monitoring, and evaluation of the above mentioned community based strategies. These studies will have two modules: the first one will be knowledge, attitudes, and practices (KAP) of the Congolese citizens and communities towards health, health care and health care seeking. The second module will be an ethnographic illness narrative study aimed at understanding the psychological rationale and anthropological beliefs underlying the most notable findings of the KAP study. Component 2: Strengthening Health Financing and Health Policy Capabilities – Total costs including contingencies US$12.5 million (of which IDA = US$1.05 million, HRITF = US$1.05 million and Government = US$10.4 million) 18. Its aim is to strengthen health care financing policy and practice in ROC both to improve equity and efficiency in health financing and to pave the way for UHC. Accordingly, the component includes the provision of technical assistance to the MOPH, Ministry of Finance and other key ministries in order improve budget formulation and allocation practices and, more generally, to strengthen health policy capacity; and the support to these institutions in their efforts to formulate a health insurance policy. 19. Component 2 is supporting component 1 and its results as it will put the focus on technical support in various dimensions of health system strengthening that has reinforcing skills of human resources both at the clinical and managerial level, hence influencing quality. It will

41

also provide opportunities to improve data collection and hence reinforcing the ability of policy development to be based on reliable data. Finally, the technical work and various support activities will strengthen the capacity of the Government to respond and better define more equitable policies and interventions hence addressing the inequeties across the system

Sub-component 2.1: Introducing fee-waivers for the poor and fee exemptions for selected services – Total costs including contingencies US$4.5 million (of which IDA = US$.38 million, HRITF = US$.38 million and Government = US$3.75 million) 20. This sub-component will draw on the experience of the Social Protection Program that is also under preparation, to promote the adoption of fee waivers and fee exemptions (as a general rule fee waivers or discounts are granted to qualifying individuals for all services, whereas fee exemptions are applied to some services, for all qualifying individuals). Project activities will seek to identify households that will benefit from fee waivers. The project may consider alternative definitions of target groups to address observed differences in health status and more effective access to health services. 21. Furthermore, the high prevalence of poverty in some regions (most departments outside of Brazzaville and Pointe Noire) may justify geographic (or group) targeting, where the group might be the population of an entire department or a subset of districts and communes in a department, where poverty rates are very high. In such areas, individual targeting may not be advisable given the high administrative costs of individual identification. By providing a waiver to all inhabitants in such areas, the leakage of subsidies may be low enough to avoid the cumbersome process of individual identification. This sub-component will also promote the adoption of fee exemptions for selected health services with high externalities and those which tend to be under-valued by the population. These exemptions will apply to all patients, not just the poor. For example, some preventive services for mothers (including some obstetric services) and children may be included in the list of exempted services.

22. This sub-component will include the following activities:

a) The project will collaborate with experts from the Social Protection Program and

once their registry is completed, this project will utilize their database to verify the poor in the targeted areas. These citizens will benefit from improved financial access to health services through enrollment into a fee-waiver program for PBF-targeted services; and

b) The project will also support the government in the development of criteria to determine which health services will be free for all citizens irrespective of socioeconomic status. Currently, the government has adopted exemptions for some medicines to treat high-prevalence infectious diseases, such as malaria and HIV/AIDS. The project will review the feasibility of this policy and will likely include other medicines and services such as preventive services for mothers and children. Finally, the project will also support the development and evaluation of pilot programs to test alternative waiver and exemption mechanisms (for example, via the Impact Evaluation).

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23. Budget formulation: As already noted above, a preliminary review of budget allocations by the MOHP to the departments suggests that certain inequalities would be overcome if the MOHP adopted an explicit budget allocation formula. An allocation formula or criterion could consider the department’s population, the per capita cost of the minimum and complementary benefit packages, the degree of remoteness, poverty, and other variables. The project will support the assessment of resource allocation, and carry out a fiscal space analysis. To this effect, project activities will include:

a) The development of formulas or explicit criteria for the allocation of government

budgets across departments to bridge gaps in resources and in access to quality health services. These formulas or criteria will be developed in close collaboration with those responsible for the development of the PBF component of the project, to ensure consistency in allocation rules;

b) The drafting and implementation of a plan for the progressive adoption of these new

budget allocation formula or criteria; and support to the MOHP and the Ministry of Finance for the incorporation of these new methods into the formulation of the national government budget for health; and

c) The development of a mechanism for a technical exchange with government officials

and other stakeholders regarding the suitability of the government’s current budget allocation to the health sector, the adoption of alternative criteria, the potential need to expand the current budget amount, and the sources of any such expansion (the question of fiscal space will arise in this context).

Sub-Component 2.2: Capacity building in health policy and management – Total costs including contingencies US$3.5 million (of which IDA = US$.29 million, HRITF = US$.29 million and Government = US$2.90 million)

24. The government of ROC has embarked on the path to reach UHC through health insurance. The project will provide technical assistance to the government of ROC to further refine the draft law, discuss the feasibility of such a reform and examine the different options and developing a timeline for implementation. Project activities in this sub-component will include:

a) Providing technical assistance to the government of ROC to discuss the feasibility, content, and timing of a UHC law. With this aim, the project will commission a document that will summarize the experience of other developing countries with similar economic indicators and level of development as ROC and identify the necessary institutional, financial and other enabling factors in order to development, inact and implement a UHC law. The document will outline the way forward for ROC. The starting point for this document will be the work already conducted by government on the health insurance initiatives of Ghana and Rwanda. b) Conducting policy workshops with government to discuss the findings and recommendations from the above review, with the aim of formulating a national consensus on the path to UHC. Participants in these workshops will include staff from the

43

MOHP, Ministry of Finance, national experts, experts from reference countries, and members from the parliament involved with inacting health laws. c) Carrying out a feasibility study on health insurance schemes which would present the Government with a series of options to be piloted at a later stage.

25. Capacity building in health policy and management: The pervasive lack of knowledge regarding health policy concepts, management skills, and regional and global best practices limits government’s ability to strengthen its health system. Along with the appropriate counterpart endorsement and partnerships, the project will:

a) Develop or adapt training materials in health policy and management, using as a

starting point those currently available from the World Bank Institute’s Flagship Program for Health System Strengthening. The training would focus on: priority setting in the health sector; development and costing of health benefits packages; methods for the targeting of government health subsidies; provider payment methods; results-based financing; and other topics that the government may consider relevant. Finally, Develop and implement a five-year training program for policymakers, and health managers, from the central and regional levels;

b) Commission national case studies that reflect the local context to use as complementary training materials; and

c) Strengthen existing capacity for research, analytical work, institutional strengthening of national institutions such as the statistic bureau, the planning department and other government entities will be developed and executed during the project period.

Sub-component 2.3: Health Sector Monitoring and Evaluation (M&E) Strengthening—Total costs including contingencies US$4.5 million (of which IDA = US$.38 million, HRITF = US$.38 million, and Government = US$3.75 million) 26. The insufficient capacity of ROCs health information system leads to inadequate monitoring and evaluation (M&E) of health sector performance and therefore an inability to use data for decision making. Several activities will be undertaken to strengthenthe monitoring and evaluation (“M&E) mechanisms in the health sector, in particular: (i) reviewing and updating the M&E framework and development plan; (ii) strengthening the M&E departments in the Ministry of Health and Population; (iii) undertaking a national health facility mapping exercise with a view to developing a master facility list including comprehensive data on health facilities; (iv) improving the health management information system; (v) developing and implementing an integrated diseases surveillance and response system; (vi) carrying out of various health facility surveys designed to assess the quality of health care; (vii) carrying out of various household surveys designed to assess the health system and its overall impact; (viii) implementing an appropriate ICT solutions program (a PBF web-enabled application); and (ix) carrying out of an impact evaluation).

27. Status of the ROC’s M&E System: The establishment and further strengthening of the M&E system was included in the PDSS and since 2011 a Sector M&E development plan was adopted and is being implemented. Today with the support of the PDSS the routine health information system produces an annual report; this had not been done for 20 years (Annuaires

44

statistiques sanitaires). During project preparation, a rapid assessment of the M&E system was conducted to review the progress, to identify the challenges and to propose solutions. The outcomes of this assessment were endorsed by the MOHP during the Pointe Noire Workshop and the overall conclusion was that the M&E system in Congo is still in its very early stages. In addition to being fragmented it does not include all the components of an integrated M&E system nor is it digitized. Its major challenges are summarized as follows:

i. The legal framework of the M&E system defining the data collection and management process is not clearly defined;

ii. Weak coordination exists among the different parties involved in M&E within and outside the MOHP;

iii. Inadequate resources are allocated to the system; there is no specific line budget for the M&E system within the health budget; the department in charge of the M&E at the ministry has limited human and financial capacity;

iv. Despite being recently revised, the data collection tools are not user-friendly and cumbersome, thus further taxing health personnel and requiring collection of data which are not utilized;

v. Delayed transmission of data within the health system. Higher levels of MOPH are receiving data several months late thus utilizing data for planning and informed decision making is not possible. Adding to this delay is that data are not digitized. There is an absence of internal or external data control and validation process: there are no defined data quality control procedures; and

vi. There is an absence of data retro information sharing process down to the data producers; and

vii. The current data collection tools do not allow full inter-operation ability with the proposed PBF system.

28. M&E strengthening within the new health project: The new draft PNDS (2013-2016) has identified strengthening of the M&E system as one of the major strategic directions. The new PDSS project will as requested by the MOHP continue to support the M&E system. The proposed support to the M&E system was discussed during the Pointe Noire Workshop and will comprise of the following elements:

i. Updating/revising the framework of the M&E system and the M&E development plan: The existing M&E framework will be revised and will clarify the roles and responsibilities of different stakeholders of the M&E system;

ii. Strengthening the MOHP M&E department at central, intermediate and lower levels: The roles and responsibilities of the M&E department at all levels will be defined within the revised M&E framework;

iii. Health facility mapping: The purpose of this survey is to help the MOHP to define the service delivery maps in the country through a census of all existing health facilities (public, quasi-public, private, etc.). The health facility mapping will contribute to the development of a Master Facility List which will include essential information about health facilities such as type of the health facility, location with geographical coordinates, available staff, provided services, etc. This master list will be updated regularly and will

45

be used in the routine HMIS and it will also be used for purposes of sampling for the facility surveys by the Impact Evaluation;

iv. Health Management Information System (HMIS): The project will support the revision of indicators with the purpose of selecting minimum core indicators, the update, the production and the dissemination of the data collection and reporting tools and the identification of the training needs, development and implementation of training program. The project will also support the development of a HMIS database for use at CSS, DDS and national levels. During the Pointe Workshop, a consensus around the use of DHIS-2 was reached and the project will provide the required support (technical, financial, etc.) to introduce and make operational the software. Data quality control process will be introduced at all levels of the health system. Performance frameworks will be introduced at the central HMIS level to strengthen its functions. In addition, the performance frameworks at the DDS, CSS and health facility levels will measure and reward performance related to timely and accurate data-collection and systematic data analysis and use;

v. Integrated Diseases Surveillance and Response (ISDR) System: Congo is an epidemic prone country with frequent outbreaks; therefore a functional disease surveillance and response system is crucial. The current system which is under the responsibility of the disease control department is being reviewed with the WHO’s support. The project will support the strengthening the ISDR.

vi. Health facility surveys: In addition to availability and access to services, quality of care is essential for good health outcomes. The quality of care will be assessed periodically through the health facilities which will focus on availability of staff, drugs, and equipment, knowledge of health workers, etc. The initial survey will be conducted during the project preparation phase as part of the impact evaluation baseline survey along with the household survey and it is proposed to carry two other surveys (midterm and end of project). These surveys might use the SDI methodology. The project will collaborate closely with the Impact Evaluation, which will also design baseline (at project start) and midterm (after two years of project implementation) health facility surveys; and

vii. Household surveys: In addition to the information provided by the above mentioned components of the M&E system, population based information will be required to make a comprehensive assessment of the health system and its overall impact on the health status of the population. For the last 12 years, two DHS (2005 & 2012) surveys were conducted in Congo and the country is planning to carry the next survey shortly. Discussions are ongoing within the MOHP whether to wait for a DHS survey every 5-6 years or explore an alternative plan (MICS, LQAS, etc.) to collect the required data. The Impact Evaluation will carry out a household survey at baseline, and at mid-term.

29. Information and Communication Technology (ICT): the project will use a web-application (Open RBF: http://openrbf.org/) to manage the public front-end, and the back-end strategic purchasing. These open-source based solutions are driving the current two scaled-up PBF approaches (Rwanda; Burundi) and are used in an increasing number of PBF pilots in Africa and Central and South-East Asia. These ICT solutions also enable conditional cash transfer or voucher programs to be managed in an integrated manner, alongside the PBF program.25 The project will work closely with the HMIS department, and assist in the 25 For an example of the application, see the one for Nigeria: http://nphcda.thenewtechs.com/

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introduction of the new DHIS-2 software. The PBF web-enabled application will be linked to the DHIS-2 software and it will be managed through the HMIS unit. The ICT solution is part of the system of intense monitoring and evaluation for PBF results. Verified and purchased results including the results for the health administration will be visible on the public website whereas the raw data will be downloadable from the website. Benchmarking both the quantity and quality of health facilities and the public health administration will lead to a powerful tool to employ results monitoring and better governance. Introducing an ICT sub-component to the project to build the capacity of the MOHP will allow the health facilities to systematically keep track of funding and payments, record data, and use this data at both the facility and central level to make informed management and policy decisions to improve the health system of ROC. 30. An Impact Evaluation will be embedded in the phased scaling-up of PBF: the HRITF will fund an Impact Evaluation (US$1.5 million), which will naturally fit into the phased scaling-up of PBF. The Impact Evaluation (see Annex 9) has a specific focus on the role of PBF, in combination with various demand-side interventions such as households visits for improved health-seeking behavior and targeting of the poor for improved financial access to a package of essential health services (links will be made with the FY14 World Bank LISUNGI Social Protection project). The Impact Evaluation design was finalized during the project appraisal mission in October 2013.

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ANNEX 3: IMPLEMENTATION ARRANGEMENTS

REPUBLIC OF CONGO


Project Institutional and Implementation Arrangements

1. The Ministry of Health and Population will implement the project through the Technical PBF Unit (CT-PBF). Project execution will take place at all levels (from the health facility to the central one) of the health system. The CT-PBF will be placed under the Director of the Cabinet (DC), with technical support from the relevant MOHP directorates. The CT-PBF is staffed by a multidisciplinary team including: a Project Coordinator (civil servant), a M&E specialist, a financial management specialist, an accountant, a procurement specialist, a health financing specialist, a public health specialist, an administrative assistant, and two support personnel. Others will be recruited as needed. Members of the CT-PBF will possess the skills and experience needed for implementing the project. Such skills could have been gained through the implementation of the current PDSS project or through other experiences in country.).

2. Additional staff will be hired such as NGO/CBO specialists (who monitor the performance of health NGOs and will be awarded contracts to implement community-based projects). The CT-PBF shall be responsible for ensuring prompt and efficient day to day coordination, implementation and communication of Project activities and results, including: (i) preparing annual work plans and budgets for onward transmission to the National PNDS Steering Committee; (ii) carrying out all of the disbursements and any procurement related to the project in accordance with the Bank approved procedures; (iii) preparing and consolidating periodic progress reports; (iv) monitoring and evaluation of Project activities; (v) liaising with other stakeholders on issues related to Project implementation; (vi) providing administrative support to implementing agencies, all in accordance with the Project Implementation Manual; and (vii); serving as the fund holder, managing the operational accounts and transferring money to the health centers and withdrawing money as needed. The Project Coordinator, responsible for signing of the countract and all aspects of project implementation, will ensure efficient implementation of the various project components, to be carried out in collaboration with the respective technical units within the MOHP.

3. The CT-PBF will respond to the National Steering Committee in place for coordinating and implementing the National Health Sector Strategy (PNDS Comité de Pilotage). The PNDS Steering Committee is chaired by Minister of Health and Populaton and includes representatives from key directorates of the MOHP, the Ministry of Planning and Economy, the Ministry of Environment, the Ministry of Finance, and representatives from the donor community (the Bank will not sit as a member of the committee but only as an observer, to avoid going beyond its mandate). The PNDS Steering Committee will oversee the implementation of PBF, review the annual PDSS II program and approve the budget, as well ensure harmonization between the implementation of the PNDS and the PDSS II. It will also

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provide guidance to the CT-PBF, and generate policy direction for the institutionalization of PBF in ROC.

4. The CT-PBF unit will coordinate and manage the project in close collaboration with the various technical units with the MoHP. The CT-PBF will be staffed by a mix of government staff and consultants recruited through a merit-based process.

5. Performance framework (Capacity Development Grants ) for the DDS: Each DDS will have a performance contract signed with the PBF unit/MOHP. The DDS performance framework will contain indicators including but not limited to (i) in collaboration with the ACV, timely and accurate application of the quantified quality checklist at the general hospitals; (ii) timely and accurate application of the performance framework for the CSS; (iii) management of the departmental vaccine supply facility and technical assistance to the CSS on the EPI; and (iv) technical assistance to and capacity building for the CSS and health facilities related to vertical programs with special emphasis on HIV/AIDS, reproductive health and tuberculosis. The DDS performance will be assessed each quarter through an independent third party.

6. Performance framework (Capacity Building Grants ) for the CSS: each CSS will have a performance contract signed with the PBF unit/MOHP. The CSS performance framework will contain indicators including but not limited to (i) timely and accurate application of the quantified quality checklist at the health centers; (ii) Establishment and management of the CSS pharmacy including timely collection of pharmaceutical re-supply orders from the CSI; (iii) formative supervision and training of health center staff; (iii) reception and validation and of HMIS data. The CSS performance will be assessed each quarter through the DDS and randomly counter-verified by the independent third party agency.

7. Performance frameworks (Capacity Building Grants ) for procurement and distribution: performance contract will be signed with the PBF-unit/MOHP and select insitutions (such as the district health units, DEP etc). Each quarter, the PBF unit will assess the procurement and distribution performance of select institutions. The performance framework will contain indicators including but not limited to: (i) the stock management of essential drugs and consumables; (ii) the timeliness and completeness of the processing of drug orders from the CSS pharmacy; (iii) the regularity and documentation of governing board meetings; and (iv) minimum stock levels for essential generic drugs at CSS pharmacies.

8. Performance framework (Capacity Building Grants ) for the drug regulatory authority/MOHP: a performance contract will be written between the MOHP and the drug regulatory authority department of the MOHP. Each quarter, this performance will be assessed by an independent third party agency. The performance framework will contain indicators including but not limited to: (i) quality assurance of generic drugs supplied by select certified drug distributors; (ii) certification of new drugs; and (iii) certification and quality assurance of pharmacies based on a work plan and post-market surveillance.

9. Performance framework (Capacity Building Grants ) for the HMIS department/MOHP: a performance contract will be written between the MOHP and the HMIS

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department of the MOHP. Each quarter, this performance will be assessed by an independent third party agency.

10. Performance framework (Capacity Building Grants ) for the PBF unit/MOHP: The PBF unit will be staffed by a mix of government staff and international and national consultants recruited through a merit-based process. Each quarter, the PBF unit will be assessed through a performance-framework by a designated committee consisting of development partners. This performance framework will contain indicators including but not limited to (i) timely processing and execution of the PBF payment orders for health facilities and health administration, (ii) timeliness and management of the national PBF steering committee meetings, (iii) maintenance of the PBF web-application front and back-end, (iv) technical support to the ACV related to contract management and verification activities and related to strategic purchasing, (v) timely and correct application of the performance framework of certified drug distributors G and the DDS, and (vi) capacity building and coordination of the overall PDSS II project.

11. Verification and counter-verification of the DDS, ACV, CSS, drug regulatory authority/MOHP and the HMIS/MOHP department performance will occur each quarter. An external evaluation agency (ACVE) will assess the performance of the ACV, DDS, CSS, HMIS department/MOHP and the drug regulatory authority/MOHP. This agency will be recruited under component 2. This ACVE will carry out each quarter:

a. verification of the performance of the HMIS and drug regulatory authority/MOHP; b. counter-verification of the quantity of services through a lot quality assurance sampling

protocol, with intense use of mobile phone technology and a community client satisfaction survey component;

c. counter-verification of a random sample of CSS and DDS performance assessments; d. counter-verify a random sample of health center quality checklists; and e. Counter-verification of a random sample of hospital quality checklists. In the case of

discrepancies surpassing 5 percent score in any of the verified samples (whether quantity, quality or performance frameworks for the CSS), a significant penalty will be applied to the performance earnings of the institution that reported this performance. The penalties for fraud will be clearly outlined in the various contracts and procedures and will be detailed in the PBF manual.

12. Ex-ante versus ex-post verification: Quarterly performance payments will be based on: (i) for health centers on ex-ante verification of quantity (ACV) and quality of health services (CSS); (ii) for hospitals on ex-ante verification of quantity (ACV) and quality of health services (DDS); (iii) for DDS and Pharmaceutical department/MOHP on ex-ante verification by a third party (ACV); (iv) for the CSS on ex-ante verification by the DDS; (v) for the certified drug distributors on ex-ante verification by the PBF-unit; (vi) for the PBF-unit on ex-ante verification by an ad-hoc committee consisting of development partners. Ex-post verification, that is, verification after payment has been made, will be carried out by the independent third party (ACVE) – through a protocol using random sampling- on the quantity of services; the quality of services; and the performance frameworks of the CSS, & DDS.

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13. The project policies and procedures will be incorporated in an implementation manual, which will be adopted by the MOHP. It will be completed by a PBF manual. The CT-PBF and the Bank will ensure that the PBF manual is consistent with the overall implementation manual. For the overall project, the table below gives a summary of role and responsibilities.

Component (or

sub-component) in which the entity is

involved

Name of the entity Ministry to which the entity

belonged

Role and responsibilities

The whole project National Steering Committee- (Comité national de coordination et suivi (CNCS) PBF

MOHP The steering committee oversees the overall project. It includes representatives from the MOHP, MOF, and development partners

The whole project PBF technical support cell

MOHP The PBF technical support cell will implement the project, and it will include consultants who will be responsible for specific program components such as technical assistance, procurement, finance and the like

Component 1 PBF technical support cell

MOHP The PBF technical support cell will (A) provide technical assistance and stewardship for the PBF approach (component 1) and (B) implement project component 2. Related to (A): Their work relates to (i) timely processing and execution of the PBF payment orders for health facilities and health administration; (ii) timeliness and management of the national PBF steering committee meetings; (iii) maintenance of the PBF web-application front and back-end; (iv) technical support to the ACV related to contract management and verification activities and related to strategic purchasing, (v)

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Component (or sub-component) in which the entity is

involved


belonged


timely and correct application of the performance frameworks of the certified drug distributors and the DDS and (vi) capacity building and coordination. Related to (B), carry out, through contracted consultants, the work program related to system-strengthening and analytical work

Component 1 MOHP Pharmaceutical department

MOHP The MOHP drug regulatory authority will be under a performance framework to regulate the certified distributors

Component 1 MOHP HMIS department

MOHP Compile, and analyze and report routine health data; manage of DHIS2 software and PBF-web enabled application; feedback of results information and capacity building in information analyis

Component 1 Certified drug distributors (to be determined, and it can include among others the Central Medical Stores)

COMEG (para -statal although nominally non-governmental ); private sector

Timely procurement of essential generic drugs and medical supplies

Component 1 Departmental Health Service (DDS)

MOHP The DDS performance framework will contain indicators related to (i) in collaboration with the ACV, timely and accurate application of the quantified quality checklist at the general hospitals; (ii) timely and accurate application of the performance framework for the CSS; (iii) management of

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involved


belonged


the departmental vaccine supply facility and technical assistance to the CSS on the expanded program on immunizations; (iv) technical assistance to and capacity building for the CSS and health facilities related to vertical programs with special emphasis on HIV/AIDS, reproductive health and tuberculosis

Component 1 District Health Service (CSS)

MOHP The CSS performance framework will contain indicators related to (i) timely and accurate application of the quantified quality checklist at the health centers; (ii) Establishment and management of the CSS pharmacy including timely collection of pharmaceutical re-supply orders from the CSI; (iii) formative supervision and training of health center staff; (iii) reception and validation and of HMIS data.

Component 1 Individual health facilities (health centers and hospitals)

MOHP and faith-based health facilities, select private for profit providers

Provision of high quality basic and complementary health services

Component 2 Contract management and verification agents (ACVs)

Local civil society organizations, contracted by the MOHP

Contract negotiation and management; verification; capacity building; data entry; participation in governance for results.

Component 2 External counter-verification agent (ACVE)

Non-governmental agency, local or international, contracted by the

An external evaluation agency will assess the performance of the ACV, DDS, CSS, HMIS department/MOHP and the drug regulatory

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involved


belonged


MOHP authority/MOHP. This ACVE will carry out each quarter: (i) a verification of the performance of the HMIS and Pharmaceutical departments/MOHP; (ii) a counter-verification of the quantity of services through a lot quality assurance sampling protocol, with intense use of mobile phone technology and a community client satisfaction survey component; (iii) counter-verification of a random sample of CSS and DDS performance assessments; (iv) counter-verify a random sample of health center quality checklists; and (v) Counter-verification of a random sample of hospital quality checklists.

Component 2 Grassroots organizations (GROs)

Local civil society

Contracted and trained by the ACV, members will carry out the community client satisfaction surveys

Components 1 and 2 (part of component 2 will strengthen this community approach)

Community Health Committees (COSAs)

Community Co-management of health facility funding; participation in planning for services; governance of planned and actual expenditures

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The table below provides additional details about how each Component or Sub-component will be implemented.

Technical

responsibility Fiduciary responsibility




1.2 Governance, purchasing, coaching and strengthening health administration through Performance-Based Financing


Component 2: Strengthening Health Financing and Health Policy Capabilities 2.1 Introducing fee-waivers for the poor and fee exemptions for selected services





HMIS unit / PBF unit DRF (MOHP)/ PBF unit

FINANCIAL MANAGEMENT AND DISBURSEMENTS

14. As part of the Congo Health Development Project-II preparation, a financial management assessment of the implementing unit within the MoHP has been carried out. The objective of the assessment is to determine: (a) whether this unit has adequate financial management arrangements to ensure that project funds will be used for purposes intended in an efficient and economical way; (b) project financial reports will be prepared in an accurate, reliable and timely manner; and (c) the project’s assets will be safeguarded. The financial management assessment (FMA) was carried out in accordance with the Financial Management Practices Manual issued by the Financial Management Sector Board on November 3, 2005. In this regard, a review of the FM existing system (budgeting, staffing, financial accounting, financial reporting, funds flow and disbursements, internal and external audit arrangements) at the MOHP’s Projects’ Coordination Unit level has been conducted.

15. This unit is currently implementing the Health Development Project-I (P106851) financed by the World Bank, the financial management staff include a Financial and Administrative Expert who is responsible for financial and administrative matters and an accountant. They have been trained in the use of Bank procedures as well as the accounting software namely TOMPRO over the last years of project implementation. Unaudited Interim Financial Reports (IFRs) for the PDSS-I are submitted on time, reviewed and found to be satisfactory. The external auditors issued a clean audit report for the year ending on December, 2012 and the management letter from the external auditors did not raise any major issues; there are no overdue audit reports and interim financial reports from this entity

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16. The assessment concluded that, the overall residual FM risk is substantial (see table below) due to Country’s weak capacity context. The project maintains proper books of accounts which include a cash book, ledgers, journal vouchers and a contract register. They prepare the necessary records and books of accounts which adequately identify, in accordance with accepted international accounting standards and practices, the goods and services financed out of the proceeds of the Grant. It is expected that the accounting system will be used for the implementation of this new project.

17. The funds will be managed through two (2) bank accounts to be opened and maintained by PCU in a commercial bank acceptable to IDA as follow: (i) a Designated Account for IDA funds and Trust Funds in CFAF to receive IDA and TF advances, and to pay for project expenditures eligible for IDA financing; and (ii) a Project Counterpart Funds Account in CFAF to receive counterpart deposits and replenishments, and to record payments eligible for ROC resources.

Country issues 18. The ROC is gradually emerging from a decade of political instability. It has enjoyed considerable economic growth in recent years, though it still depends too narrowly on the oil sector. The country reached the HIPC completion point in 2009, but its institutions are still weak. Structural reforms have been launched in the areas of economic governance, public expenditure management, and transparency. The ongoing Transparency and Governance Capacity Building Project financed by the World Bank is helping the country strengthen capacity in public administration and tackle corruption and mismanagement.

19. Although there is cause for cautious optimism (significant improvements have been made in public finance management and oil revenue management through the IDA project on transparency and governance support as well as other donor-financed projects), it will take a long time for these reforms to yield substantial improvement in the management of public funds. Given the fragility of the fiduciary environment, the Government has requested to use a ring-fenced approach to implement this project, similar to the other Bank-financed Projects in the country.

Risk assessment and mitigation

The following risk identification worksheet summarizes the significant risks with the corresponding mitigating measures.

Risk Risk Rating

Risk Mitigating Measures Incorporated into Project Design

Conditions for Effectiveness (Y/N)

Residual Risk

Inherent risk Country level According to questions 13

H

None. Beyond the control of the project. The government is committed to a reform program

N

H

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Risk Risk Rating



Residual Risk

and 16 of the CPIA, Congo is a high risk country from the fiduciary perspective. The CIFA, PER and the PEFA reports outlined PFM weaknesses at central and decentralized government levels as well as sector ministries level in term of governance and public funds management.

that includes the strengthening of the PFM, an ongoing IDA-financed PFM Reform project (PRCTG-II) is being implemented but is unlikely to yield results quickly enough to impact the proposed project. Use of IDA FM procedures is required for this project.

Entity level The project is embracing a new approach that is not yet familiar to the wider stakeholders. The project will attempts at tackling key health system reforms. The assessment of some ministries during the PEFA and particularly the Mininitry of Finances revealed internal control weaknesses and weak fiduciary environment.

S Relying on a dedicated FM within the Technical PBF Unit and use of IDA FM requirements is critical for the mitigation of fiduciary risk of this project; the adoption of a FM manual of procedures which is part of the PIM will help to mitigate internal control weaknesses. The PIM will be ready to be used at project launch. The government is dedicated to launching new reforms to improve the livelihood of population.

N M

Project level: This is a project which will be implemented across different levels that will face coordination challenges. Ensuring funds are used for purposes intended both at the central and the decentralized levels will be a challenge.

S The CT-PBF will strengthen ex-ante and ex-post control of activities implemented/managed by implementing entities. Training on fiduciary procedures will be conducted for all FM staff throughout the life of the project. Clear TORs for each responsibility will be agreed between the parties involved to ensure clear understanding to include timeframes for reporting. The project fiduciary team will be supported by the PBF technical staff.

N S

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Risk Risk Rating



Residual Risk

Control Risk S S Budgeting: The Annual Work Plan and Budget (AWPB) will be prepared by the PCU and approved by the Steering Committee based on the policy guideline. The budgeting process will be fairly complex. Inputs are required from all implementing entities. This could result in delays in the preparation of the budget. Weak capacity at the implementing entities to prepare and submit accurate work program and budget; weak budgetary execution and control; weak monitoring leading to some overrun expenditures

S The project implementation manual will define the arrangements for budgeting, budgetary control and the requirements for budgeting revisions. Annual detailed disbursement forecasts and budget required. IFR will provide information on budgetary control and analysis of variances between actual and budget.

N M

Accounting: This project will use the accounting software as for all other World Bank financed project in RoC. It is already using the TOMPRO software the risks will relate to poor policies and procedures, delay in keeping reliable and auditable accounting records.

S The project will adopt the OHADA accounting system. Accounting procedures will be documented in the manual of procedures (ii) The FM functions will be carried out by a qualified consultants; the existing software will be customized to take into consideration the need for this new project. Staff will continue to be trained on the use the accounting software.

N S

Internal Control: Internal control system may be weak due to weak FM capacity of Internal Audit (IA); Insufficient safeguards and controls may result in

S Revision and adoption of a FM Procedures Manual and training on the use of the manual by the consultant recruited for this purpose. The FM team will work closely

N

M

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Risk Risk Rating



Residual Risk

misuse of funds and impact the implementation of the project.

with the others members of the PBF team including the two NGO/CBO specialists.

Funds Flow: One Bank account will be opened in a reliable Bank for IDA and TF; a separate account will also be opened at the same Bank for the counterpart, all project activities will be financed through these Bank accounts. Risk of misused funds; and (ii) delays in disbursements of funds to IA and beneficiaries; (iii) delays in the release of government contributions (e.g. mainly the subsequent tranches after initial deposit).

S The following are the mitigating measures: (i) Payment requests will be approved by the FM Manager prior to disbursement of funds. (ii)The ToRs of the External Auditors will include physical verification of goods, services acquired. (iii) Close follow up will be made to ensure that the RoC will release US$ counterpart funds 20 million as initial deposit before effectiveness and subsequent tranches according to a disbursement schedule to be agreed upon during appraisal and confirmed in the Financing Agreement

N Y (counterparts funds)

S

Financial Reporting The CT-PBF will provide a quarterly Interim Financial Report (45 days after the end of each quarter; annual Financial Report (within six months after the year-end) to the Bank in order to monitor the utilization of funds for the project. The risk will be to have inaccurate and delay in submission of IFR to the WB due to delays from IAs or weak capacity of the FM team.

S (i) A computerized accounting system will be used. (ii) IFR and financial statements formats similar will be agreed and will be part of the PIM that will be available at project launch;

N M

Auditing: No auditing arrangement in place; the national audit capacity is weak and not reliable. Delay in

S (i) The project’s institutional arrangements allow for the appointment of adequate external auditors (independent auditors) and the ToRs will include physical

N S

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Risk Risk Rating



Residual Risk

submission of audit report or qualified opinion and delays in the implementation of audit reports recommendations.

verification and specific report on finding of physical controls of goods, and services acquired or delivered. (ii) Annual auditing arrangements will be carried out during the project implementation period in accordance with ISA.

Governance and Accountability Possibility of circumventing the internal control system with colluding practices as bribes, abuse of administrative positions, mis-procurement etc, is a critical issue.

M (i) The TOR of the external auditor will comprise a specific chapter on corruption auditing (ii) FM procedures manual which is part of the PIM will be prepared and approved by project launch; (iii) Robust FM arrangements (qualified individual FM staff recruited under ToRs acceptable to IDA, quarterly IFR including budget execution and monitoring; (iv) Measures to improve transparency such as providing information on the project status to the public, and to encourage participation of civil society and other stakeholder are built into the project design.

N M

OVERALL FM RISK S S The overall residual FM risk rating is deemed (Substantial). Implementing entity 20. The existing Project Coordination Unit which will be renamed Technical PBF Unit (CT-PBF) within the MoHP will have the overall responsibility of implementing this project. It will oversee the project’s fiduciary aspects (Financial Management and Procurement); the financial management team will be composed of one financial expert, one chief accountant and one accountant. These positions will be fullfilled through a competitive selection process which should be completed before effectiveness. The fiduciary team will be trained on the use of World Bank procedures as well as project’s software.

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Planning and budgeting 21. The Annual Work Plan (AWP) and budget along with the disbursement forecast will be consolidated into a single document by the Financial Management unit of the project, which will be submitted to the National PNDS Steering Committee for approval, and thereafter to IDA for approval no later than December 31 of the year proceeding the year the work plan should be implemented. The CT-PBF will monitor its execution with the accounting software in accordance with the budgeting procedures specified in the manual of procedures and report on variances along with the quarterly interim financial report. Only budgeted expenditures would be committed and incurred so as to ensure the resources are used within the agreed upon allocations and for the intended purposes. The quarterly IFRs will be used to monitor the execution of the AWP.

Information and accounting system 22. The RoC is a member of the Organisation pour l’Harmonisation en Afrique du Droit des Affaires (OHADA), thus, adheres to its accounting standards, (Syscohada), in line with the international accounting standards. Hence Syscohada accounting standards will apply to this project. An integrated financial and accounting system is in place and will be updated to accommodate this project; this update should be completed no later than three months after effectiveness. The Project code and chart of accounts will be developed to meet the specific needs of the project and documented in the Manual of Procedures. The charter of account should be prepared according to the wording used in tables for sources and uses of funds for the accepted eligible expenditures as agreed during negotiations of the Project. These diaries and records should be maintained with the support of financial management software that should be operational no later than three (3) months after Project effectiveness. Financial management staff at the CT-PBF should also be trained in the use of the software by the same date.

23. Internal control and financial, administrative, and accounting manual: The internal control system of the Project will be described in the financial management manual. Such manual should be flexible enough to allow for improvement and changes as necessary during Project implementation. This manual should be fully aligned with the accounting elements mentioned above as well as the modules of FM software. CT-PBF already has an FM and accounting procedures manual that was prepared for the current Health Project. The FM manual of procedures which is part of the PIM has been revised as to take into account the specific aspects of the proposed Project. Such revision was carried out by the project fiduciary team.

24. Flow of funds: Project activities will be financed through two Bank accounts that will be opened in a commercial bank acceptable by the Association. The accounts will be managed according to the disbursement procedures described in the PIM and Letter of Disbursement for the Project. The ceiling of the accounts will be set to the equivalent four months of forecasted project expenditures and should take into account the disbursement capacity of the various structures implementing the Project. The aggregate ceiling will be set at CFAF 700 million (CFAF 350 million for IDA and CFAF 350 million for the HRITF). Additional advances will be made on a monthly basis against withdrawal applications supported by Statements of Expenditures (SOE) or records and other documents as specified in the Disbursement Letter.

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25. Disbursement arrangements (disbursement methods): Given the high risk environment, the report-based disbursement will not be applicable by default. Therefore, upon project effectiveness, transaction-based disbursements will be used. An initial advance up to the ceiling of the DA (XAF 700 million) will be made into the designated account and subsequent disbursements will be made on a monthly basis against submission of SOE or records as specified in the DL. Hereafter, the option to disburse against submission of quarterly unaudited IFR (also known as the Report-based disbursements) could be considered subject to the quality and timeliness of the IFRs submitted to the Bank and the overall FM performance as assessed in due course. The other methods of disbursing the funds (reimbursement, direct payment and special commitment) will also be available to the project. The minimum value of applications for these methods is 20 percent of the DA ceiling. The project will have the option to sign and submit Withdrawal Applications (WA) electronically using the eSignatures module accessible from the Bank’s Client Connection website.

26. Disbursements by category: The table below sets out the expenditure categories to be financed out of the Credit/Grant proceeds. This table takes into account the prevailing Country Financing Parameters for the Republic of Congo in setting out the financing levels which allow up to 100 percent financing. Notwistanding, the borrower has elected to co-share the cost of the project and consequently, the percentage of eligible expenditures represents IDA/HRITF share of the project costs.

26 Total project cost is US$120 million of which IDA financing is $10 million, thus 8% of total cost, HRITF financing is US$10 million thus 8% of total cost and government counterpart financing is $100 million thus 84% of total cost. Hence IDA + HRITF financing constitute 16% of total project cost.

Category Amount of the Credit

Allocated (expressed in

USD)

Amount of the Grant Allocated

(expressed in USD)

Percentage of Expenditures to be Financed Per Source of Funds

(inclusive of Taxes)

(1) PBF Grants under Component 1.1 of the Project

7,478,731

7,478,731

8%26

(2) PBF Capacity Development Grants under Component 1.2 (i) of the Project

688,048

688,048

8%

(3) Goods, non-consulting services, consultants’ services, Training and Operating Costs under Component 1.2 (ii) and 2 of the Project

1,833,221

1,833,221

8%

TOTAL AMOUNT 10,000,000 10,000,000

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27. For Components relating to PBF, the project funds will flow to one integrated sub account which is already being used at the facility level for each health facility from the bank accounts. The facilities maintain separate cash book and ledger for each source of funding and report performance on pre-defined package of health services using an agreed standard reporting format which will be included in the financial procedures manual. The MOHP will consolidate expenditures under different categories and report to IDA as one line item “PBF to facilities” (one line for each facility).

28. Each health facility will prepare a “work plan” for implementing such activities which will be approved by the project implementing unit. The funds flow will follow the same pattern proposed for PBF under one Category, but the expenditures will be reported by activities. An agreed standard reporting format will be used for this category/component which will be included in the financial procedures manual and consolidated or a separate manual of procedures will be prepared for PBF components.

29. Financial reporting: The CT-PBF will prepare on a quarterly basis the Interim Unaudited Financial Report (IFRs). These reports will be submitted to IDA on a quarterly basis within the 45 days following the end of each quarter. The reports will include: (i) a table with sources and use of funds; (ii) table with use of funds per activity; (iii) table regarding use of funds according to procurement methods and threshold; and (iv) a table with monitoring and evaluation or physical advance of activities. Financial statements will be prepared for each financial exercise covering in general twelve (12) months. Interim financial statements will also be prepared taking into account (i) certified status of expenditures; and (ii) an analysis of DA management, counterpart funding as well as Trust Funds. The format of such reports will be discussed and agreed by effectiveness of the project.

IDA Trust Funds Governemnt of Congo

IDA and TF accounts in FCFA

Counterpart funds in FCFA

Transactions to be financed in all currencies (FCFA, US$, Euro, etc.)

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30. External Audit: The assessment of the “Cour des Comptes”, the Supreme Audit Institution during the PEFA and subsequent PFM evaluation revealed a need for improvement of its capacity and could not be used to audit the project accounts. Therefore, a qualified, experienced, and independent external auditor will be recruited on approved terms of reference three months after effectiveness. The external audit will be carried out according to either International Standards on Auditing (ISAs) or Auditing Standards (ASs) and will cover all aspects of project activities implemented and include verification of expenditures eligibility and physical verification of goods and services acquired. The report will also include specific controls such as compliance with procurement procedures and financial reporting requirements and consistency between financial statements and management reports and field visits (e.g. physical verification). The audit period will be on annual basis and the reports including the project financial statements submitted to IDA and the Cour des Comptes will be submitted six months after the end of each fiscal year.

31. The project will comply with the Bank disclosure policy of audit reports (e.g. make publicly available, promptly after receipt of all final financial audit reports (including qualified audit reports) and place the information provided on its official website within one month of the report being accepted as final by the team.

32. Governance and Accountability: the risk of fraud and corruption within project activities is high given the country context, inherent risks of activities. However, the proposed fiduciary arrangements will help to mitigate such risks. Nonetheless, the following measures are envisaged to further mitigate the risk of fraud and corruption; mainly the CT-PBF to implement an Anti-corruption Action Plan under the oversight of the Government Anti-corruption Watchdog – “Observatoire Pour la Lutte Contre la Corruption.

33. Financial Management Action Plan: The Financial Management Action Plan described below has been developed to mitigate the overall financial management risks.

Issue Remedial action recommended Responsible

entity Completion date FM

Conditions

Accounting software

Update the existing software and train the fiduciary staff on the use of that software.

CT-PBF Three months after effectiveness

No

Counterpart funds

Payment of the first tranche of the government contribution

CT-PBF By effectiveness Yes

External auditing

Selection of an external auditor on ToRs (project accounts)

CT-PBF Six months after effectiveness

No

34. Conclusion and Supervision Plan: Supervisions will be conducted over the project’s lifetime. The project will be supervised on a risk-based approach. It will comprise inter alia, the review of audit reports and IFRs, advice to task team on all FM issues. Based on the current risk assessment which is (substantial) the project will be supervised at least twice a year and may be adjusted when the need arises. The Implementation Status and Results Report (ISR) will include a FM rating of the project. An implementation support mission will be carried

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before effectiveness to ensure the project readiness. To the extent possible, mixed on-site supervision missions will be undertaken with procurement monitoring and evaluation and disbursement colleagues.

PROCUREMENT ARRANGEMENTS

35. Applicable guidelines: Procurement for the proposed project would be carried out in accordance with the World Bank’s "Guidelines: Procurement under IBRD Loans and IDA Credits" dated January 2011; and "Guidelines: Selection and Employment of Consultants by World Bank Borrowers" dated January 2011; and the provisions stipulated in the Legal Agreement. The various items under different expenditure categories are described below. For each contract to be financed by the Grant (TF) and Credit, the different procurement methods or consultant selection methods, the need for pre-qualification, estimated costs, prior review requirements and time frame will be agreed between the Borrower and the Bank in the Procurement Plan. The procurement plan will be updated at least annually or as required to reflect the actual project implementation needs and improvements in institutional capacity.

36. Procurement documents: Procurement will be carried out using the Bank’s Standard Bidding Documents (SBDs) or Standard Request for Proposals, respectively for all International Competition Bidding (ICB) for goods and international recruitment of consultants. For National Competition Bidding (NCB), while waiting for the Bank to assess the implementation of the new procurement system based on experience gained from the Government’s use of these documents outside the context of this Project, the Borrower will use the Bank’s SBD for ICB for good and the Bank’s Standard Request for Proposals for recruitment of consultants.

37. National procurement system and ongoing reforms: The main recommendations of the 2006 Country Procurement Issue Paper (CPIP) were to (i) prepare and approve a public procurement code, (ii) carry out a survey of the existing capacity on procurement, (iii) make a needs assessment of the institutional and human capacity requirements for public procurement in the country, (iv) prepare an action plan for the procurement reform, and (v) implement the new procurement code in accordance with the agreed action plan. All these recommendations have been implemented.

38. Indeed, the Government has finalized the major actions to implement the new procurement code and the said code is already being applied by Government since September 2009. The most important steps achieved to date include the following: (i) the draft national procurement code finalized and approved by the national authorities; (ii) the staff of the DGCMP (prior reviewing institution) is already in place; (iii) the board of the regulatory body (ARMP) is nominated by the government, the private sector and the civil society as recommended by the new provisions; (iv) the standard bidding documents are reviewed and approved by the procurement reform committee; and (v) an action plan for the training of main actors has been properly implemented. An independent audit is ongoing in the purpose of verifying the extent to which the rules are respected by the contract authorities

39. Conditions to use of the national procurement code: Since the Bank has found the national procurement system acceptable; it may be authorized to use it for all contracts for

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goods and services (other than consultants’ services) under NCB procurement method subject to modification of clauses or practices that should not be partially or entirely applicable to a bank funded operation. This application refers to the decree itself, the texts of application, the related standard bid documents and national institutions assigned control and regulation function. The national competitive bidding procedures currently in force in the ROC deviate slightly from the World Bank Procurement Guidelines NCB procedures for procurement of Goods and services (other than consultants services).

40. If the government modifies the procurement code itself or one or more texts of application that includes the SBD after the agreement on the clauses to be modified or to be neutralized, the Bank has the right to review the said modifications, so as to check to what extent they are in compliance with Bank procurement guidelines and procedures. After its review, the Bank will simply notify the government its recommendations on the clauses to modify or to cancel. This exercise will be done any time the government modifies the procurement code or the texts of application.

41. Advertising procedure: The General Procurement Notice (GPN), Specific Procurement Notices (SPN), Requests for Expression of Interest, and the results of the evaluation and contract awards should be published in accordance with the advertising provisions in the Bank procurement guidelines.

Procurement Methods 42. Procurement of Goods and Non consultancy services: Goods procured under this project will include: equipment; office furniture. Non consultancy services procured under this project will include payement health facilities, workshops and training in the region and abroad. Procurement will be done under ICB or NCB using the Bank’s Standard Bidding Documents for all ICB and National SBD agreed with or satisfactory to the Bank. Small value goods may be procured under shopping procedures. United Nations Agencies and direct contracting may be used where necessary if agreed in the procurement plan in accordance with the provisions of paragraph 3.7 to 3.8 and 3.10 of the Procurement Guidelines. The following additional methods may be used where appropriate: Procurement under Public Private Partenership Arrangements (PPP); Performance Based Procurement; Community Participation in Procurement.

43. Selection of Consultants: Consultancy services would include various advisory services, studies; training and technical assistance the selection method will be Quality and Cost Based Selection (QCBS) method whenever possible. Contracts for specialized assignments estimated to cost less than USD 300,000 equivalent may be contracted through Consultant Qualification (CQ). The following additional methods may be used where appropriate: Quality Based Selection (QBS); Selection under a Fixed Budget (FB); and Least-Cost Selection (LCS).

44. Least-Cost Selection (LCS) may be used for selecting consultants for assignments of a standard or routine nature, such as audit services, where well-established practices and standards exist.

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45. Single Source Selection (SSS) may be employed with prior approval of the Bank and will be in accordance with paragraphs 3.8 to 3.11 of the Consultant Guidelines. All services of Individual Consultants (IC) will be procured under contracts in accordance with the provisions of paragraphs 5.1 to 5.6 of the Guidelines.

46. Short lists of consultants for services estimated to cost less than the equivalent of US$100,000 per contract may be composed entirely of national consultants in accordance with the provisions of paragraph 2.7 of the Consultant Guidelines. However, if foreign firms express interest, they will not be excluded from consideration.

47. Training, workshops, seminars, and conferences: Training activities will comprise workshops and training in the region and abroad, based on individual needs as well as group requirements; on-the-job training, and hiring consultants for developing training materials and conducting training. All training and workshop activities will be carried out on the basis of approved annual programs that will identify the general framework of training activities for the year, including: (a) the training envisaged, (b) the personnel to be trained, (c) the selection methods of institutions or individual conducting such training, (d) the institutions conducting the training, if already selected, (e) the duration of the proposed training, and (f) the cost estimate of the training. Attendance at relevant project workshops and seminars will be treated as training and will need Bank’s no objection in advance of the training.

48. Operating Costs: The operating costs would include reasonable expenditures for office supplies, vehicle operation and maintenance, communication and insurance costs, banking charges, rental expenses, office and office equipment maintenance, utilities, document duplication/printing, consumables, travel cost and per diem for project staff for travel linked to the implementation of the project, and salaries of contractual staff for the project, but excluding salaries of officials of the recipient’s civil service, meeting and other sitting allowances and honoraria to said staff.

Procurement implementation arrangements 49. Project Oversight: The existing Procurement capacity under the line ministry procurement Unit of the MoHP (Cellule de gestion des Marchés Publics du Ministère de la Santé et Population) will be used to handle the fiduciary functions. The procurement performance of the unit has been moderately satisfactory for the last two years.

50. In addition to their daily responsibilities, the Procurement Expert in place or to be recruited will provide the following services: (i) develop and strengthen the capacity on procurement for all staff in line ministry involved in the project implementation , (ii) coach and mentor the procurement Unit (iii) reinforce the integrity and internal review of the procurement process, (iv) oversee and advise on procurement related matters, (v) ensure the quality of procurement activities, and (vi) draft no objection requests for all procurement decisions subject to prior review by the Project Coordinator. The Procurement Expert will have specific performance criteria in his TOR to measure procurement quality and delay and how knowledge is transferred to staff in the line ministry.

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51. Midterm Review: An independent audit and evaluation will be carried out to assess the capacity in the project execution when implementing activities funded under resources using the new Procurement Code. The midterm review report will integrate the results of the procurement activities performed during the period preceding the date of such report and will set out the measures recommended concerning the use of the national procurement code for the remaining activities of the project if satisfactory to the Bank.

52. If any exceptions to the procurement code will be needed in order to be acceptable to the Bank, an amendment to the FA will need to be introduced prior to the Bank’s accepting the use of the national procurement code.

53. Assessment of the Procurement Unit capacity to implement procurement: An assessment of the existing Procurement Unit capacity to implement procurement activities for the project was carried out. The assessment reviewed the internal arrangements for handling procurement, the organisational structure for implementing the project, and the capacity of staff responsible for procurement activities under the proposed project. The assessment also reviewed the interaction between the project staff responsible for procurement and the new structures witch implemented the new procurement code. The assessment found that the Procurement Unit has currently limited capacity and does not have the required staff with necessary qualifications and experience to handle the project procurement activities; therefore, it is recommended that the Procurement Unit will continue to benefit from the support and assistance of the procurement expert in place or to be recruited.

54. Assessment of risks and mitigation measures: The risk factors for procurement performance include the country context and the low procurement capacity of the MoHP. This ministry will be in charge of project implementation with the support and technical assistance of experts of the existing coordination unit. In terms of the sector and country context, the CPIP and the experience of other IDA- and IFI-funded projects indicate that procurement on the project is likely to involve the following risks:

(a) A weak governance environment, weaknesses in accountability arrangements, and an

overall lack of transparency in conducting procurement processes creates significant risks of corruption, collusion and fraud;

(b) The administrative system as it operates in practice creates opportunities for informal interference in the procurement process by senior officials – creating opportunities for waste, mismanagement, nepotism, corruption, collusion and fraud;

(c) Government officials are likely to be involved in project procurement through tender committees and the national control system ensuring that the rules are respected and able to handle complaints from bidders may not be familiar with procurement procedures; and

(d) The control and regulatory system does not fully and totally operate in an independent manner.

55. The overall project risk for procurement is substantial before risk mitigation.

56. Measures to mitigate the risks: The following strategy has been developed to mitigate procurement risks identified:

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(a) To mitigate risks related to the low level of capacity at the Procurement Unit in the

MoHP, all proposed procurement decisions at a given threshold (see table below) will be subject to mandatory review by a contract committee composed of members proposed by the coordination Unit committee but any staff involved in evaluation and contract award processes should be excluded;

(b) All consulting contracts costing above US$300,000, ICB contracts for goods will be published in the UNDB online and on the Bank’s external website, in accordance with World Bank Guidelines;

(c) The government project team will apply a 'one-strike' policy to all contractors and consultants - any case of complicity in corruption, collusion, nepotism and/or fraud will lead to dismissal, disqualification from all further project activities and prosecution;

(d) A project launch workshop will be conducted for the moHP staff and relevant staff of all other entities involved in project implementation;

(e) For all procurement, the PIM includes procurement methods to be used in the project along with their step by step explanation as well as the standard and sample documents to be used for each method; and

(f) The MoHP, in close relation with the coordination unit, will create a data base of suppliers of the required goods, and consultants (firms and individuals). The database will also include information on current prices of goods.

Schedule of Risk Mitigation Action Plan to be carried out

Action Responsibility Due Date Remarks

1 Procurement Plan for the first 18 months prepared and agreed with the Bank

MoHP Before negotiations

Was done for negotiations

2 Update its project record management system.

MoHP No later than 6 months after project effectiveness

To better keep procurement documents and reports

3 Training of Staff (at least two) on World Bank procurement procedures in specialized institutions

MoHP Not later than one year after project effectiveness

To improve project staff skills in Bank procurement

57. Implementation readiness: The following actions will be initiated/carried out while waiting for project launch, expected in April 2014:

a) A detailed Procurement Plan for the first 18 months of the project was prepared and and agreed upon during negotiations.

b) The General Procurement Notice (GPN) will be advertised locally and in the United Nations Development Business (UNDB) online and the DgMarket after Board approval.

c) The most important procurement activities for the key contracts of the first year will be initiated and negotiated but the contract will not be signed till the project launch.

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58. Fraud, coercion, and corruption: All procuring entities, as well as bidders, suppliers, and contractors, shall observe the highest standard of ethics during the procurement and execution of contracts financed under the project in accordance with paragraph 1.16 and 1.17 of the Procurement Guidelines and paragraphs 1.23 and 1.24 of the Consultants Guidelines.

59. Frequency of Procurement Supervision: In addition to the prior review supervision to be carried out from Bank offices, the capacity assessment of the implementing agency has recommended (i) supervision missions every six months to visit the field, and (ii) at least one annual post procurement review (PPR). Missions shall include a Bank Procurement Specialist or a specialized Consultant.

60. Procurement audit: A procurement audit would be carried out at least every year during project implementation and report on the procurement process, contract management, fiduciary compliance, and so forth.

61. Procurement Planning: The Borrower developed a draft procurement plan for project implementation, which provides the basis for the procurement methods. This plan was agreed between the Borrower and the Project Team during negotiations. It will be available in the project’s database and on the Bank’s external website. The Procurement Plan will be updated in agreement with the Bank annually or as required to reflect the project implementation needs and improvements in institutional capacity.

Procurement methods and World Bank Review requirements

(a) Procurement methods and Bank review and for Goods, and Consulting Services

Procurement Methods Threshold for the method in 1000 USD

Bank review in 1000 USD

(a) International Competitive Bidding (ICB)

USD 1000 or more for goods All contracts

(b) National Competitive Bidding (NCB)

All contracts estimated below the ICB threshold and above

shopping ceiling

Post review

(c) Shopping Below USD 100 for goods Post review

(d) Direct contracting (DC) N/A All contracts (e) Procurement under Public Private Partenership Arrangements (PPP)

N/A All contracts

(f) Performance Based Procurement N/A All contracts (g) Community Participation in Procurement

N/A All contracts

(h) United Nations Agencies N/A All contracts (b) Selection methods and bank review for Contracts for consultant services

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Procurement Methods

Selection methods

threshold in 1000 USD

Prior Review Threshholds

(a) Selection based on quality and cost (SBQC)

NA All contracts estimated above US$ 100,000

(b) Selection Based on the Consultants’ Qualifications (QC), LCS, SCBD,

100 All contracts estimated above US$ 100,000

© Individual Consultants (IC) N/A All contracts estimated above

US$ 100,000 (d) Single Source Selection (SSS)

N/A All contracts

62. The agreed and approved procurement plan will determine procurement methods and the contracts to be submitted to Bank review and no objection.

63. The Bank standard bid documents for goods and the bank standard RFP (Requests for Proposals) will be used for all ICB contracts and contracts for consultant advertised internationally. The same documents will be used for contracts advertised locally until the Bank has found acceptable the utilization of the standard bid documents and RFP developed with the national procurement system. For the purpose of clause 2.7 of the consultant guidelines, for all contracts estimated below the equivalent value of USD 100,000, the short list may comprise only local firms.

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ANNEX 4: OPERATIONAL RISK ASSESSMENT FRAMEWORK (ORAF)

REPUBLIC OF CONGO

Health System Strengthening Project II (PDSSII)

.

Risks

.

Project Stakeholder Risks

Stakeholder Risk Rating Moderate

Risk Description: Risk Management:

The Minister of Health is committed to improving the health of its population as well as to reach the most vulnerable. Within the MOH, the current PDSS project's implementation unit consists of dedicated and knowledgeable individuals who have been trained and are well versed in Bank procedures, project implementation, and PBF. However, as the project is fully implemented by the MoHP, weaknesses remain within the Ministry when it comes to fiduciary processing and engaging the various units in the Ministry in implementing some of the activities.

Implementing a successful PBF project relies on a strong sense of commitment and ownership from the government counterpart; the Ministry of Health is very dedicated to this project and to institutionalizing PBF in the Congo. The World Bank team will build on the Ministry’s strong commitment; during project preparation as technical assistance will be provided to the stakeholders at all level to have a better understanding of PBF and to support their formulation of free health care for specific services and the poorest households. Workshops will be conducted to share experiences from the region, to achieve a common understanding of the issues at hand and to plan for implementation. In addition, the relevant units in charge of the fiduciary and disbursement aspects will be also trained and put on a performance framework. . The Bank team has made substantial investments in bringing the current leadership at the highest levels on board with the concept and challenges ahead. During project preparation and implementation donor agencies and relevant ministries will be consulted and given the opportunity to provide inputs to the design of the project activities. UN agencies have already shown their interest is supporting PBF and have been trained in this area. Civil society involvement: CSOs are present in ROC. The Bank has had consultations with the civil society and professional associations regarding the project and they are fully on board regarding this. Civil society organizations will be involved in community-based facility management and verification of outputs of the project.

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The Bank will continue its policy dialogue with the Government and provide technical assistance for implementing the PBF reforms.

Resp: Both Status: In Progress

Stage:

Both Recurrent:

Due Date:

Frequency:

Implementing Agency (IA) Risks (including Fiduciary Risks)

Capacity Rating Substantial


Implementing Agency There might be potential risk regarding the capacity of MOH counterparts to implement PBF. Even though PBF has been piloted in the ROC over the last year, there is a lack of familiarity among MOH personnel on the intricacies of PBF, how it will be implemented and what their role would be in this new scheme.

There is a very strong training/capacity building sub-component in this project, this will ensure that all levels of MOHP staff are well versed in the details of PBF and PBF implementation. They will be trained in processes and will have a clear understanding of their role before the project is launched. Close supervision of the project will take place by the team; additionally a very experienced full-time PBF person based in Brazzaville will be hired to manage the process on the ground. The institutional arrangements for the purchasing agency and the counter verification are not yet finalized but both will likely involve non-governmental entities who will carry this out. Additional international (South-South) expertise will be provided in order to ensure a smooth transition to effectiveness and implementation. The health administration will be incentivized at all levels to carry out their functions better.

Resp: Client

Status: In Progress

Stage:

Both Recurrent:

Due Date:

Frequency:

Governance Rating Substantial


Weak governance including in PBF contract negotiations and management (contract award, monitoring & evaluation, fraud and corruption prevention, etc) could result in contracts that do not deliver value-for-money Autonomy to health centers to spend

The institutional arrangements for the project consider Governance as a core activity. To be transparent in its process, a very detailed PBF manual will be created and shared with main stakeholders; and the purchasing, verification and technical assistance will be mostly contracted-out at the time of the project launch. In addition, decentralize governing boards will be created for PBF at the department level, and will involve civil society in approving verified PBF invoices. Finally, governance mechanisms will be strengthened at the health facility levels (COGEs) by involving them in the oversight over public funds (which includes user fees generated by the health facility, but also government funds and PBF income). Additionally,

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PBF revenues may lead to mismanagement of funds.

grassroots organizations will be enlisted to do client satisfaction surveys.

Resp: Client

Status: In Progress

Stage:

Both Recurrent:

Due Date:

Frequency:

Resp: Client

Status: In Progress

Stage:

Both Recurrent:

Due Date:

Frequency:

Project Risks

Design Rating Substantial


The team is of the view that an IPF design is suited for complementing Government contribution to this project. However, the project is complex by the mere fact it is trying to introduce rigorous health sector reform initiatives at different levels and this can be an issue for the technical team since it will result in creation of new structures and in depth supervision at all these levels.

The project will take into account lessons learned from other similarly designed PBF projects in other African countries as well as from the initial operational evaluation of the RPB pilot in ROC. The ministry’s teams will be strengthened with technical assistance from experts from the country or the region. This project will use experienced PBF practioners to ensure a high level of technical support during design and implementation to try and mitigate issues that may crop us as a result of complex project design. The project team will also initiate several pre-launch workshops to ensure that all stakeholders are well informed of the project design, objective and implementation measures. Additional training will be executed to strengthen the Government’s understanding of health care financing and the various ways for resource mobilization and allocation.


Stage:

Both Recurrent:

Due Date:

Frequency:

Social and Environmental Rating Low


The country has continued to build its capacity on safeguards management during the implementation of several World Bank financed projects including the predecessor of this project PDSS. No adverse environmental or social impacts are expected and the overall social impact is expected to be positive.

The project does not require any land acquisition leading to involuntary resettlement and/or restrictions of access to resources and livelihood. Thus, the project is expected to have a positive impact for all direct and indirect beneficiaries, including vulnerable groups such as children, women and the poor who are the main target beneficiaries of the project. An Indigenous Peoples Health Needs Assessment has been conducted as part of the current PDSS (P106851) project and has been used as a starting point to develop the Indigenous Peoples Plan Framework (IPPF). To ensure inclusion of Indigenous Peoples an Indigenous People’s Planning Framework is been prepared and disclosed in country in November 2013.

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The expected impacts are positive as the IPs do not have access to quality care and hence the project will ensure that quality free care is provided to them to ensure a better health outcome.

Resp: Client

Status: In Progress

Stage:

Both Recurrent:

Due Date:

Frequency:

Program and Donor Rating Moderate


Few international partners are present in ROC and there is a coordination effort to ensure that the government’s priorities are being responded to by the various partners. It will be important that the other partners are on board to contribute to the desired technical assistance and supplemental financing needed to respond to the health needs in ROC in order to build a coherent system

The World Bank and the PDSS II team are coordinating with other development partners in the ROC. During project preparation and implementation donor agencies and relevant ministries will be consulted and given the opportunity to provide inputs. The international partners will be also part of the training efforts and some of the UN agencies have already been trained and are very keen to support PBF implementation. The team will work with the DPs to clarify everyone’s role and ensure that each DP is involved in a way that is constructive for both the client and the DP.


Stage:

Both Recurrent:

Due Date:

Frequency:

Delivery Monitoring and Sustainability

Rating Moderate


Monitoring and Evaluation are not being used effectively in the current PDSS project; furthermore, the National Health Information System is weak and doesn't produce reliable data.

Monitoring and Evaluation (M&E) is a key component of this project; data are critical in order to inform the Government, the World Bank and other development partners about the results and impacts of the various sub-components. More specifically the project will finance: (i) annual process evaluation; (ii) spot checks; (iii) one full impact evaluation, and (iv) annual independent audits of the system. PBF is designed in a way that it provides 100% data availability from all PBF systems, through an open platform (see for instance the Nigerian one http://nphcda.thenewtechs.com). These data are publicly available to inform decision makers and managers at all levels. There are also complete monthly and quarterly health facility assessments which feed into this public forum. In addition, there are quarterly community client satisfaction surveys which will inform the public and the government on client satisfaction

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Resp: Client

Status: In Progress

Stage:

Implementation

Recurrent

:

Due Date:

Frequency:

Overall Risk

Overall Implementation Risk: Substantial

Risk Description: The overall risk rating is substantial; the preparation and implementation risk are substantial. Given the above discussion of the key risks and issues the team is cautious about the overall risk, but is optimistic that the various mitigations measures explained in the ORAF coupled with the Government’s commitment will help to avert such risks during preparation and implementation.

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ANNEX 5: IMPLEMENTATION SUPPORT PLAN

REPUBLIC OF CONGO


STRATEGY AND APPROACH FOR IMPLEMENTATION SUPPORT

1. The Implementation Support Plan (ISP) focuses on mitigating the risks identified in the ORAF, and aims at making implementation support to the client more flexible and efficient. It also seeks to provide the technical advice necessary to facilitate achievement of the PDO (linked to results/outcomes identified in the result framework), as well as identify the minimum requirements to meet the Bank’s fiduciary obligations.

Technical: Implementation support will include: (a) progress on objectives (b) fine tune strategies where required (c) drawing lessons from the implementation for wider applicability.

Financial management. Implementation support will include: (a) reviewing submitted reports and providing timely feedback to the implementing agency; (b) supporting the development of the internal audit function within the MOHP; (c) providing training and support to the accountants within the DAGE.

Procurement. Implementation support will include: (a) providing additional staff and training as needed for the MOHP and PDSS II team; (b) reviewing procurement documents and providing timely feedback to the MOHP and PDSS II team; (c) providing detailed guidance on the Bank’s Procurement Guidelines to the MOHP and PDSS II team and (d) monitoring procurement progress against the detailed Procurement Plan.

Environmental and Social Safeguards. The Bank team will supervise the implementation of the updated Medical Waste Management Plan and provide guidance to the MOHP and PDSS II team. In addition the Bank will provide the needed supervision to ensure that needs of the Autochthone are taken into account in the health services package as identified in the IPPF.

Other Issues. Sector level risks will be addressed through policy dialogue with the governments’ Ministries.

Implementation Support Plan 2. Despite the Bank’s experience in the country, the wide geographical scope and innovations in the project will require fairly intensive supervision, especially during the first two years of implementation. The Bank team members will be based either in Washington DC, or in Country Offices, and will be available to provide timely, efficient and effective implementation support to the clients. Formal supervision and field visits will be carried out at least 2 times annually. These will be complemented with monthly video conferences to discuss project progress. Detailed inputs from the Bank team are outlined below:

Technical, Policy and legal/Regulatory inputs. Technical, policy and legal/regulatory related inputs will be required to review bid documents to ensure fair competition, sound

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technical specifications and standards, and confirmation that activities are in line with Government’s health sector strategies.

Fiduciary requirements and inputs. Training will be provided by the Bank’s financial management and procurement specialists as needed. The Bank team will also help identify capacity building needs to strengthen financial management capacity and to improve procurement management efficiency. Financial management and the procurement specialists will be based in the country office to provide timely support. Formal supervision of financial management and procurement will be carried out semi-annually.

Safeguards. Inputs from environment and social development specialists will be provided as needed.

Operation. The Task Team will provide day-to-day supervision of all operational aspects, as well as coordination with the clients and among Bank team members. Relevant specialists will be identified as needed.

Table 2: Implementation Support Plan

Time Focus Skills Needed Resource Estimate (US$)

First twelve months

Capacity building for the PBF and study tour

PBF Bank expert 300,000 (IDA +HRITF SPN)

Capacity building for health Care financing

Health financing Bank consultant

Development of the targeting system

SP staff and Health specialist

Development of the TORs for the unified hospital information system

Hospital information system specialist

Capacity building on FM, procurement and internal audit

FM and procurement staff, and consultants

Impact Evaluation baseline survey and capacity building on Impact Evaluation

PI/AFTHW staff + Co-PI who is an expert in Impact Evaluation

12-48 months

Implementation support

Same as above 150,000 each subsequent year

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Skills Needed Number of Staff Weeks Number of Trips Comments Task team leader 10 SWs annually Fields trips as

required Washington based

Procurement 5 SWs annually Fields trips as required

Country office based

FM Specialist 5 SWs annually Fields trips as required.


Nutrition Specialist 1 SW annually Fields trip as required

Country Office based

Environment specialist

1 SW annually Field trip as required

DC based

Health Specialist

5 SWs annually Fields trips as required

DC based

M&E Specialist 4 SW annually Fields trips as required


RBF Specialist

8 SW annually Fields trips as required

DC based

Health financing specialist


DC based

SP (targeting) Specialist


DC based

Economist 4 SW annually Fields trip as required


Governance Specialist



Impact Evaluation Specialist


DC based

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ANNEX 6: PROJECT COST

REPUBLIC OF CONGO


Project Cost By Component and/or Activity

US$ million

IDA (8.3%)

HRITF (8.3%)

Government(83.4%)

TOTAL

Component 1: Improvement of utilization and quality of health services at health facilities through PBF (US$107.5 million)


7.27 7.27 72.98 87.5

1. Governance, purchasing, coaching and strengthening health administration through Performance-Based Financing

1.68 1.68 16.68 20

Sub-total 1 8.95 8.95 89.6 107.5 Component 2: Strengthening Health Financing and Health Policy Capabilities (US$12.5

million) 2.1 Introducing fee-waivers for the poor and fee exemptions for selected services

.38 .38 3.75 4.5


.29 .29 2.90 3.5


.38 .38 3.75 4.5

Sub-total 2 1.05 1.05 10.4 12.5 TOTAL 10.0 10.00 100.00 120.00

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ANNEX 7: WHAT IS PERFORMANCE BASED FINANCING

REPUBLIC OF CONGO


1. Performance-Based Financing (PBF) is a supply-side Results-Based Financing (RBF) approach.27 PBF pays for outputs or results and this is different from classical programs which focus on procuring inputs. In the health sector, outputs or results are predominantly produced by health facilities whereas some results are produced by the health administration. Such outputs or results include quality services produced by health facilities and certain actions by the health administration. Income from PBF is used by health facilities and the health administration to procure necessary inputs and to pay performance bonuses.

2. PBF is based on operational and tacit knowledge developed over the past 15 years in South-East Asia and Africa, and is in continuous development incorporating lessons learned. The effectiveness of PBF was proven through a rigorous Impact Evaluation in Rwanda.28 A PBF toolkit is being developed by the World Bank and will be available in the first quarter of 2014.29

3. PBF is applicable in a wide variety of lower and middle income country contexts. The diversity and the applicability of PBF are evident when looking at the contexts where such programs are carried out: Burundi, DRC South-Kivu and Nigeria versus Indonesia, Kyrgyzstan and Vietnam. Currently, over 30 countries in Africa, and Central and South-East Asia are planning, designing, and implementing such programs. PBF has expanded rapidly in Sub-Saharan Africa; see image below.

27 Musgrove, P. (2011). Financial and Other Rewards For Good Performance or Results: A Guided Tour of Concepts and Terms and a Short Glossary. Washington DC. 28 (i) Basinga, P., P. Gertler, et al. (2011). Effect on maternal and child health services in Rwanda of payment to primary health-care providers for performance: an impact evaluation. The Lancet 377: 1421-1428; (ii) Gertler, P. and C. Vermeersch (2012). Using Performance Incentives to Improve Health Outcomes. Policy Research Working Paper WPS6100. Washington DC, The World Bank. Walque, D. d., P. J. Gertler, et al. (2013); (iii) Using Provider Performance Incentives to Increase HIV Testing and Counseling Services in Rwanda. Policy Research Working Paper WPS6364. Washington DC, The World Bank. 29 Fritsche, G., editor (2014). Performance-Based Financing Toolkit. The World Bank, Washington DC.

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Figure 1: Rapid expansion of PBF projects in Sub-Saharan Africa between 2006 and 2013

4. Certain aspects of PBF and how they relate to the Republic of Congo will be discussed in the following sections. These aspects are: (a) purchasing quality services; (b) separation of functions; (c) health facility autonomy; (d) verification and counter-verification; and (e) data management and invoicing

Purchasing Quality Services 5. PBF purchases quality health services. Important notions are leveraging existing resources; changing incentive structures; purchasing balanced packages; purchasing conditional on quality; and PBF pricing versus the real cost of services.

6. PBF purchases quality health services through leveraging existing means of production. The purchase is through a fee-for-service provider payment mechanism, conditional on the quality of services. Key to understanding PBF is the notion of leveraging. Existing building, equipment, medical consumables, cash income from other sources and staffing are leveraged through PBF.

7. PBF changes incentive structures at various levels in the health system. The incentives need to be strong enough to influence health worker coping strategies while they provide additional income to enable health facilities to procure missing equipment, to maintain and repair equipment and premises and to stock essential life -saving drugs.

8. PBF purchases a balanced package of services at the community & health center level and at the first referral hospital level. A lack of coverage for essential health services guides purchasing at the community & health center level. At the hospital level additional services complementing the primary levels are purchased; for instance complicated deliveries or more sophisticated reproductive health services. In general, there are 15-25 services in each package. Ideally, incentives are targeted at preventive services used by everybody whilst facilitating access to curative services for the poorest. PBF budget allocation is about 2/3 at the community and health center level, and 1/3 for the first referral hospital level.

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9. Quality is measured and rewarded through the use of a quantified quality checklist. This checklist is custom-made to reflect the particularities of each context. It is measured once per quarter, typically by an incentivized district health administration (for the health centers) or by a peer-evaluation mechanism (for the hospitals). The impact of the quality measure depends on the type of PBF system. It can be a quality bonus with a maximum of 25 percent of earnings (in the ‘carrot’ system) or a deduction of 100 percent of earnings if the quality is 0 (in the ‘stick’ system).

10. PBF fees have little to do with the actual cost of services. First, the actual cost of a service (which includes apportioned annuity of building and equipment; staff cost; drugs and medical consumables) is much higher than a PBF fee for that service. Second, PBF is a pricing system; the fee is proportional to the relative public health importance and the level of coverage of that service. Third, a PBF fee includes a rural hardship element, and therefore the fee is higher in harder to reach areas. Finally, certain services can be targeted to the poorest of the poor and attract a higher fee than the same service for the better off. Also, PBF fees can be changed depending on budget availability; upward if more money becomes available, and downward if the disbursement is higher than expected.

11. A simplified example of PBF is provided in table 1. The bulleted list with bracketed numbers that follows this paragraph shows how the performance of the health facility is financed and how the health facility chooses to use the financing. In this example, individual health facilities are provided funds based on the quantity and quality of services they produce as independently verified. Each bracketed number refers to a field in table 1. For example, [1] refers to the number of children the health facility has fully immunized in the past quarter.

[1] If a health facility fully immunizes 60 children in a quarter; [2] The health facility could earn US$120 (60 × US$2 per child fully immunized); [3] The health facility could earn US$1,080 for 60 deliveries because each delivery earns

US$18. A typical minimum package of PBF services at a health center would contain 15–25 services;

[4] This health facility would earn US$2,196 as unadjusted subtotal for the services it produced over the past quarter;

[5] The total amount would be adjusted for the remoteness or difficulty of the facility (equity bonus), because urban or peri-urban facilities could earn a disproportionate amount. In the example in table 1, this particular facility would earn 20 percent more because of the difficulties it faces;

[6] The total would also be adjusted by a quality score based on a checklist administered at the facility every quarter. This facility would earn 60 percent of what it would be entitled to because of the quality correction. The quality correction is a maximum of 25 percent of earnings from the past quarter [6]. This facility thus earns 60 percent of the 25 percent for its quality;

[7] The funds earned (US$3,030 in this example) are transferred to the bank account of the facility;

[8] In this example, the health facility also has some other sources of cash revenue (US$970), and these are added to the PBF earnings;

[9] The health facility had US$4,000 in income over the past quarter, and the expenses section illustrates how this could have been used. The income can be used for

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(a) Health facility operational costs, such as drugs and consumables, outreach expenses, and health facility maintenance and repair;

(b) Performance bonuses for health workers (up to 50 percent) according to defined criteria; this facility decided to spend 26 percent of its total income on performance bonuses (34 percent of its PBF earnings; however, because of other sources of cash income, such funds are managed integrally); and

(c) Savings; this health facility is saving not only to buy a motorcycle to facilitate community outreach but also to have a cash buffer.

Table 1: Simplified Example of How Performance-Based Financing Works in a Health Facility

Health facility revenues over the previous period Number provided

Unit price (US$)

Total earned (US$)

Child fully vaccinated 60 2 120

Skilled birth attendance 60 18 1,080

Curative care 1,480 0.5 740

Curative care for the vulnerable patient (up to a maximum of 20% of curative consultations)

320 0.80 256

[A typical minimum package for a health center would contain 15 to 25 services.]

- - -

Subtotal 2,196

Remoteness (equity) bonus +20% 439

Quality bonus 60% of 25% 395

Total PBF subsidies 3,030

Other revenues (direct—insurance, and so on) 970

Total revenues 4,000

Health facility expenses

Fixed salaries staff 800

Operational costs 350

Drugs and consumables 1,000

1 2

3

5

6

7

8

4

84

Health facility revenues over the previous period Number provided

Unit price (US$)

Total earned (US$)

Outreach expenditures 250

Repairs to the health facility 300

Savings into health facility bank account 250

Subtotal 2,950

Bonuses to staff in the facility = total expenses minus subtotal 1,050

Total expenses 4,000

Separation of Functions 12. A precondition for obtaining credible performance results is a separation of functions. It is best practice to strive for a full separation of functions between the chief players in the health care arena: the fund-holder, the purchaser, the provider, the community, community health committees, local PBF steering committees and the national PBF coordination mechanisms.

13. In a separation of functions different functions are allocated to different health system stakeholders. In PBF, the following functions are distinguished: Provision; Regulation; Purchasing; Fund holding and Community voice. In figure 2 below, the separation of functions is illustrated:

Figure 2: The Separation of Functions and its Governance Issues30

30 Remme, M., P.-B. Peerenboom, et al. (2012). Le Financement base sur la Performance et al Bonne Gouvernance: Leçons apprises in Republique Centrafricaine. PBF Community Of Practice Working Paper Series WP8 ed.

9

85

Health Facility Autonomy 14. Health facility autonomy is an important pre-requisite for PBF. Health facility autonomy is important in (i) holistic management of cash resources; (ii) managing a bank account; (iii) procurement of goods; (iv) repairs to facility and equipment; and (v) managing human resources.

15. Community oversight is important when decentralizing public funding. To enhance governance, community oversight mechanisms are strengthened when available, or introduced when absent.

Verification and Counter-Verification 16. Credible verification is at the heart of PBF systems and two types can be discerned.

a. The first type is the so-called ‘ex-ante verification’; the verification before payment for performance is made. The ex-ante quantity verification is typically carried out by a third party contracted to do the purchasing on behalf of the fund holder(s) and regulator. The ex-ante quality verification is frequently carried out by the district health administration through a performance contract.

b. The second type is the ‘ex-post verification’; the verification which is done after payment for performance has been carried out. Whereas the ex-ante verification is routinely (monthly and quarterly) carried out for all contracted health facilities, the ex-post verification is done on a random sample of health facilities and health administrations. Different systems exist, but the ex-post quantity verification is typically carried out by the purchasing agent, through grassroots organizations. Such mechanisms are also called ‘community client satisfaction surveys’. On the one hand, such systems discourage the ‘phantom patient phenomenon’ (a service claimed that did not take place), and on the other they collect valuable feedback from the community on their perception of the quality of these services. Ex-post verification is also done on performance frameworks that are predominantly assessed through internal mechanisms, and on the quality checklists.

Data management and invoicing

17. PBF needs good data-management and invoicing systems to pay regularly for performance. Such PBF data-management and invoicing systems are characterized by (i) limited data-sets; (ii) good data accuracy; (iii) a high degree of data completeness; (iv) good data accessibility, and (v) transparency. In an increasing number of PBF projects, a web-enabled application is used. A public frontend makes accessible information on performance and payments to the general public. Accessibility to these web-enabled applications down to the district level is reasonable in lower and middle-income countries, and this accessibility is improving with growing connectivity.

18. PBF data management and invoicing systems are purposefully linked to decentralized governance mechanisms. In well-designed PBF systems, a district level steering committee acts as a district-level governing board for PBF. Such decentralized decision making is important as knowledge on how health facilities function is best at the district level.

86

Purposefully linking civil society and government systems in this steering committee enhances governance significantly. Timely access to good quality data and invoices through the web-enabled application effectively enable such governance mechanisms.

87

ANNEX 8: ECONOMIC AND FINANCIAL ANALYSIS

REPUBLIC OF CONGO


I. INTRODUCTION

1. This document presents the methods and findings of the economic and financial evaluation of sub-component 1.1 the Health Sector Strengthening Project II (HSSP II) project in the Republic of Congo (ROC). Sub-component 1.1 consists of performance payments to health facilities for expanding quantity and improving quality of selected health services. It belongs to project Component 1 which seeks to improve utilization and quality of health services at health facilities through Performance-Based Financing (PBF). Other project components are not included in this evaluation because it is difficult to ascribe quantifiable benefits to them. Thus, this evaluation does not consider the costs and benefits of project sub-component 1.2 “Governance, purchasing, coaching and strengthening health administration through Performance-Based Financing” and project component 2 “Strengthening Health Financing and Health Policy Capabilities” which consists mostly of technical assistance. Overall, the economic and financial evaluation considers project activities worth US$87.5 million, out of total project costs of US$107.5 million, or 81 percent of the total. 2. Describing the project intervention that is the subject of this evaluation is indispensable to understand the methods used and to interpret the results. Thus, what follows is a brief conceptual description of project sub-component 1.1. II BRIEF DESCRIPTION OF THE PROJECT INTERVENTION SUBJECT TO THIS EVALUATION 3. Sub-component 1.1 of the project will pay performance bonuses to government health care providers. The financing of health services without and with the HSPP II project is described schematically in Figure 1. As is shown on the left hand side of the figure (scenario “Without the project”), government health care providers, both ambulatory and inpatient, rely on user fee revenue to finance part of their recurrent costs, primarily medicines. Providers use that revenue to replenish their stocks of medicines with the government drugs procurement system, run by the Congolese Company of Essential Generic Medicines (COMEG), or with any of several private distributors of medicines that operate around the country.

88

Figure 1 : Financing of health services in ROC: Scenarios without and with the HSSP II project

4. In government health facilities utilization of some basic health services is low, as a result of limited physical access to facilities, low quality of care, a lack of incentives for health personnel to improve quality and quantity of services, and the existence of user fees that constitute a financial barrier to access to households. It is estimated that the average Congolese makes 0.2 curative ambulatory visits to government health facilities (Integrated Health Centers, or CSI from their acronym in French) per year. That is equivalent to 1 visit per person every five years. Such a low rate of utilization is at odds with the high prevalence of infectious diseases in the country, including malaria, respiratory and intestinal infections, HIC, tuberculosis, and others. 5. Part of the recurrent cost of service provision is currently financed by government, through its budget for the Ministry of Health (MOH), and part by users, through out-of-pocket (OOP) payments. User fees are set independently by each government health provider as no policy exists regarding the kinds and levels of user fees. 6. Project sub-component 1.1 will modify the current scenario in two ways, as is shown on the right-hand side of Figure 1: (1) it will supplement the revenue of health providers by paying a bonus for each unit of service delivered to nonpoor patients; and (2) it will pay a larger bonus for each unit of service delivered to a patient that has qualified as poor under the project. These bonuses will reward the provider for delivering one extra unit of service and will allow the provider to lower its user fees both to nonpoor and poor patients, although the drop in fees is expected to be higher for poor patients.

89

Economic evaluation 7. The economic evaluation contrast the costs incurred by the project, under sub-component 1.1, with the benefits that arise as a result of the services that are financed by the project. The bonuses paid through the project are expected to lead to an increase in the quantity and quality of selected health services in health centers and district hospitals (see a full list of these services in the Project Appraisal Document). Each additional unit of service delivered will lead to an improvement in the patient’s health status. This improvement is measured in Disability Adjusted Life Years (DALYs), a common measure of effectiveness of health projects (Jamison, Breman et al. 2006). Intuitively, one DALY is a somewhat similar measure to one year of healthy life saved. The ratio between the costs of the bonuses incurred by the project to generate the additional unit of service and its effectiveness is commonly known as the cost-effectiveness ratio, and is measured in dollars per DALY. The cost-effectiveness ratio can be seen, on an intuitive level, as the cost that is required to gain one additional year of health life by a project beneficiary. Gains in health life result from a reduction in premature mortality and in disability.

Health services delivered in health centers (the Minimum Package of Activities) 8. The project will pay bonuses for a total of 23 services that are provided in health centers. These facilities are known in ROC as Centres de Santé Intégrés, or Integrated Health Centers (CSI). The 23 services are listed in Table 3 below. The table also shows the amount of money that the project is expected to allocated to each of these services, to finance the performance bonuses. It is difficult at this stage to determine precise allocations of project resources among these services. The allocation shown is preliminary. It is proportional to the number of services contained in each of several subgroups of interventions. More information is necessary to produce an allocation that can be supported by empirical data. In particular, the unit cost of services and the actual utilization figures at the present time would be needed to determine a more rational allocation. The bibliographical sources that support the cost-effectiveness ratios for these 23 interventions are presented in Table 4. 9. As can be seen at the bottom of Table 3, a total amount of XFA 32,477 million (US$66.9 million) are expected to be allocated to CSI services. The combined cost-effectiveness ratio of these services over the project’s five year life is estimated to be US$65 per DALY. To put this figure in perspective, it can be roughly interpreted as follows: saving a year of health life for a project beneficiary costs US$65. This is a mere 2 percent of the annual per capita Gross Domestic Product in ROC, equal to US$3,154.31 The set of health center services that the project will finance appears to be highly cost-effective.

31 Amount in current dollars, not adjusted by purchasing power parity.

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Table 3: Health center services to be subject to performance bonuses through the project

N° Category Category name Activities

Total project

cost (XAF

million)

Total project

cost (US$

million)

Intervention number

(see Table 4)

Selected cost-

effectiveness ratio

(US$/DALY)1 MPA-B Curative consultations for adults and children New curative consultation

2,015 4.1

MPA 5 112

2 MPA-B Curative consultations for adults and children New curative consultation – indigent

2,015

4.1

MPA 5 112

3 MPA-C High cost services Admission day 308

0.6

MPA 3 23

4 MPA-C High cost services Admission day - indigent 308

0.6

MPA 3 23

5 MPA-C High cost services Minor surgery 308

0.6

MPA 22 109

6 MPA-A Preventive consultations for mother and son Fully vaccinated child 1,428

2.9

MPA 2 7

7 MPA-A Preventive consultations for mother and son Growth monitoring: child aged 0-11 months newly registered for growth monitoring

1,428

2.9

MPA 1 10

8 MPA-A Preventive consultations for mother and son Growth monitoring : child aged 12-23 months seen for growth monitoring

1,428

2.9

MPA 1 10

9 MPA-A Preventive consultations for mother and son Growth monitoring : child aged 25-59 months see for growth monitoring

1,428

2.9

MPA 1 10

10 MPA-A Preventive consultations for mother and son Child 0-59 months treated for moderately severe malnutrition

1,428

2.9

MPA 4 42

11 MPA-A Preventive consultations for mother and son Antenatal consultation (new and standard visit)

1,428

2.9

MPA 7 112

12 MPA-A Preventive consultations for mother and son PMTCT : pregnant woman MPA 9 21

91

tested for HIV 1,428 2.9 13 MPA-A Preventive consultations for mother and son ANC: VAT 2-5

1,428 2.9

MPA 10 261

14 MPA-A Preventive consultations for mother and son ANC: IPT 1,428

2.9

MPA 11 41

15 MPA-B Preventive consultations for mother and son Post natal consultation 2,015

4.1

MPA 12 112

16 MPA-C High cost services Institutional delivery 308

0.6

MPA 14 112

17 MPA-A Preventive consultations for mother and son FP: New and recurrent user of modern FP method (OAC and injection)

1,428

2.9

MPA 6 30

18 MPA-B Curative consultations for adults and children Referral for a severe condition arrived at the hospital

2,015

4.1

MPA 15 109

19 MPA-A Preventive consultations for mother and son Home visit : (domestic waste disposal ; latrine ; ITN available ; access to clean water ; FP use – incl. Condom-, vaccination status ; nutritional status children)

1,428

2.9

20 MPA-B Curative consultations for adults and children HIV+ client under CTX prophylaxis

2,015

4.1

MPA 18 53

21 MPA-A Preventive consultations for mother and son Voluntary counseling and testing for HIV (VCT)

1,428

2.9

MPA 13 87

22 MPA-B Curative consultations for adults and children AFB+ PTB patient (tuberculosis) 2,015

4.1

MPA 17 221

23 MPA-B Curative consultations for adults and children AFB+ PTB patient treated and cured (tuberculosis)

2,015

4.1

MPA 17 221

Total project cost for MPA services (US$) 32,477

66.9

Weighted cost-effectiveness ratio (US$ per DALY) 65

92

Table 4: Cost effectiveness ratios for health center (MPA) services and bibliographical references

Intervention number of name Intervention

Cost-effectiveness ratio (US$/DAL

Y)

Selected

cost-effectiveness ratio (US$/DAL

Y)Comment Source

MPA 1

Nutritional services for children aged 6 to 59 months

Vitamin A capsules <age 2 10 10 Average value

DCPP (2008) Stimulating Economic Growth Through Improved Nutrition

11 DCPP (2007) Eliminating Malnutrition Could Reduce Poor Countries’ Disease Burden by One-Third Improved Nutrition

Growth monitoring and counseling

8-10 Jamison et al (2006). Disease Control Priorities in Developing Countries, p. 560

MPA 2

Vaccinated child Hib, and hepatitis B, diphtheria, pertussis, and tetanus

296 7 Smallest value

Ibid

Measles 4 Ibid BCG vaccine 68 Ibid Traditional expanded

program on immunization (EPI)

7 Ibid

MPA 3

Admission day 23 23 No information avalable for health centers. Same value used as that for hospitals.

MPA 4

Nutritional services for children aged 6 to 59 months

Child survival program with nutrition component

41-43 42 Average value

Jamison et al (2006). Disease Control Priorities in Developing Countries, p. 560

93




Y)

Selected


Y)Comment Source

MPA 5

Curative consultations for children and adults

Rapid diagnostic tests for malaria

75 112 Average value

WHO (2008) Cost-effectiveness of malaria diagnostic methods in sub-Saharan Africa in an era of combination therapy

Management of childhood illnesses

218 DCPP (2008) Using Evidence About “Best Buys” to Advance Global Health

Malaria prevention 24 DCPP (2008) Using Evidence About “Best Buys” to Advance Global Health

Diarrhea treatment (oral rehydration therapy)

132 DCP (2006) Disease control priorities in developing countries p.45

MPA 6

New acceptors of modern contraceptive methods

Average Costs per Benefit of Family Planning

30 30 Disease Control Priorities in Developing Countries (no date) Contraception, chapter 57

MPA 7

Antenatal care visits for pregnant women

Syphilis screening 19 Terris-Prestholt F. et all (2003) Is antenatal syphilis screening still cost effective in sub-Saharan Africa

MPA 8

Prenatal care Prenatal care consultations 82-142

112 Average value

Jamison et al (2006). Disease Control Priorities in Developing Countries, p. 46.

MPA 9

Prevention of Mother to Child Transmission (PMTCT)



MPA VAT 2-5 127- 261 Avera Jamison et al (2006). Disease Control Priorities in

94




Y)

Selected


Y)Comment Source

10 394 ge value

Developing Countries, p. 54.

MPA 11

Pregnant women receiving two doses of Intermittent preventive Treatment (IPT) for malaria

41 41 Average value

Dandaji A. (no date) Cost-Effectiveness of Intermittent Preventive Treatment of Malaria in Pregnancy in Southern Mozambique

MPA 12

Postnatal care Postnatal consultations; no information available on cost-effectiveness

82-142

112 Assumed same value as prenatal care

Jamison et al (2006). Disease Control Priorities in Developing Countries

MPA 13

Pregnant women receiving HIV counselling and testing

VCT in Kenya 27 87 Average value

Sweat M. (2000) Cost-effectiveness of voluntary HIV-1 counseling and testing in reducing sexual transmission of HIV-1 in Kenya and Tanzania. The Lancet.

VCT in Tanzania 45 Sweat M. (2000) Cost-effectiveness of voluntary HIV-1 counseling and testing in reducing sexual transmission of HIV-1 in Kenya and Tanzania. The Lancet.

VCT in Generalized lowl- 14- Jamison et al (2006). Disease Control Priorities in

95




Y)

Selected


Y)Comment Source

level epidemic in Sub-Saharan Africa

261 Developing Countries, p. 339.

MPA 14

Deliveries Delivery care 82-142

112 Average value


MPA 15

Referral for a severe condition arrived at the hospital

Assumed to below to the category "Surgical services and emergency care" contained in the reference shown.



MPA 16

Admission day (Health center)

Only two studies are reported in the Diseased Control Priorities Project which have attempted to estimate the cost-effectiveness of a small district hospital in a poor country.

11 11 McCord, C. 2003. "A cost effective small hospital in Bangladesh: what it can mean for emergency obstetric care." International Journal of Gynecology & Obstetrics no. 81 (1):83-92. doi: 10.1016/s0020-7292(03)00072-9.

Snow, R., V. Mung’ala, D. Forester, and K. Marsh. 1994. “The Role of the District Hospital in Child Survival at the Kenyan Coast.” African Journal of Health Sciences 1 (2): 71–75.

MPA Treatment of 14- 221 Jamison et al (2006). Disease Control Priorities in

96




Y)

Selected


Y)Comment Source

17 tuberculosis 429 Developing Countries, p. 68. 12 Jha, P., O. Bangoura, and K. ranson. 1998. "The cost-

effectiveness of forty health interventiones in Guinea." Health Policy and Planning no. 13 (3):249-262.

MPA 18

HIV treatment with CTX prophylaxis

53 53 Abimbola TO, Marston BJ. (2012) The cost-effectiveness of cotrimoxazole in people with advanced HIV infection initiating antiretroviral therapy in sub-Saharan Africa. J Acquir Immune Defic Syndr.

97

Health services delivered in district hospitals (the Complementary Package of Activities) 10. In hospitals the project will finance bonuses for a total of 18 different services. They are shown in Table 5. The references on the cost-effectiveness of these interventions are presented in Table 6. The bonuses to be paid for these services are expected to cost a total of XAF 10,022 million (US$20.6 million). Here, also, bonuses have been allocated among services using the same criterion described above for health center services. A more rational allocation will have to wait for more accurate data to be obtained during an upcoming pre-appraisal mission to ROC. The combined cost-effectiveness ratio of these hospital services is shown at the bottom of Table 5 and is US$86 per DALY. It is somewhat less cost-effective than the set of health center services. This is the case because the more costly and complex health services delivered in hospitals tend to be on the whole less cost-effective than the more basic preventive and curative services delivered in health centers. 11. The total cost of the entire sub-component 1.1 is shown at the bottom of Table 5 and is XAF 42,499 million (US$87.5 million). The overall cost-effectiveness ratio of the services financed through the project in health centers and hospitals is estimated at US$70 per DALY. Again, this is a relatively high cost-effectiveness ratio. In other words, allocating this volume of project resources to performance bonuses for health care providers yields good value for money. Project effects on access to health services and on the poor 12. According the ROC’s National Health Accounts study (Ministère de la Santé et de la Population 2013) in 2010 households financed through out-of-pocket (OOP) payments about 37 percent of all health care costs in the country. By lowering the user fees to patients in government health facilities, the project will promote greater access to health services and will also help to alleviate poverty. As is shown below in the Financial Evaluation of the project, performance bonuses will almost equal current OOP payments by poor households and they should cover a substantial portion of OOP payments for nonpoor households.

98

Table 5: District hospital services to be subject to performance bonuses through the project

N° Catego

ry Category name Activities

Total project

cost (XAF

million)

Total project

cost (US$ million)

Intervention

number (see Table

6)

Selected cost-

effectiveness ratio

(US$/DALY)

1 CPA-A Curative consultations for adults and children (Hospital)

Outpatient consultation by an MD 101

0.2

CPA 25 101


Outpatient consultation by an MD of an indigent

101

0.2

CPA 25 101

3 CPA-B High cost services (Hospital) Admission day 1,273

2.6

CPA 19 23

4 CPA-B High cost services (Hospital) Admission day - indigent 1,273

2.6

CPA 19 23


Referred patient arrived at the hospital and counter-verification arrived at the HC

101

0.2

CPA 25 101

6 CPA-B High cost services (Hospital) Major Surgery 1,273

2.6

CPA 28 178

7 CPA-B High cost services (Hospital) Institutional delivery - normal 1,273

2.6

CPA 28 178

8 CPA-B High cost services (Hospital) cesarean section 1,273

2.6

CPA 26 178

9 CPA-B High cost services (Hospital) Institutional delivery - complicated 1,273

2.6

CPA 28 11


Client under ARV treatment seen six-monthly

101

0.2

CPA 29 407


VCT 101

0.2

CPA 13 87


PMTCT: HIV+ pregnant client put under ARV protocol

101

0.2

CPA 24 192


PMTCT: newborn from an HIV+ mother put under ARV protocol

101

0.2

CPA 24 192

99


FP: New and recurrent user of modern FP method (OAC and injection)

101

0.2

CPA 6 30


FP: new user of IUD or implant 101

0.2

CPA 6 30

16 CPA-B High cost services (Hospital) FP: bilateral tuba ligation and vasectomy 1,273

2.6


AFB+ PTB patient 101

0.2

CPA 30 43


AFB+ PTB patient treated and cured 101

0.2

CPA 30 43

Total project cost for CPA services (US$) 10,022

20.6

Weighted cost-effectiveness ratio (US$ per DALY)

86

Total project cost for CPA and MPA services 42,499

87.5

Total project cost-effectiveness ratio (US$ per DALY)

70

100

Table 6: Cost effectiveness ratios district hospital (CPA) services and bibliographical references Intervention Cost-

effectiveness ratio (US$/DALY)

Selected cost-effectiveness ratio (US$/DALY)

Comment

Source

CPA 19

Admission day (Hospital)

Only two studies are reported in the Diseased Control Priorities Project which have attempted to estimate the cost-effectiveness of a small district hospital in a poor country.

11 23 Average value selected

McCord, C. 2003. "A cost effective small hospital in Bangladesh: what it can mean for emergency obstetric care." International Journal of Gynecology & Obstetrics no. 81

The authors report cost effectiveness ratio of $178 per life saved for a hospitalization. This was divided by 5 which is the average length of stay of hospitalizations in ROC.

36 (a) Jha, P., O. Bangoura, and K. ranson. 1998. "The cost-effectiveness of forty health interventions in Guinea." Health Policy and Planning no. 13 (3):249-262 and (b) Robberstad, Bjarne. 2005. "QALYs vs DALYs vs LYs gained: What are the differences, and what difference do they make for health care priority setting?" Norsk Epidemiologi no. 15

CPA 20

New curative consultation (Hospital)

CPA 21

Deliveries (Hospital) Delivery care 82-142 112 DCP (2006) Disease control priorities in developing countries

CPA 22

Surgical services and emergency care

Minimum 6 109 Average value

101




Comment

Source

selected Maximum 212 CPA 23

Inpatient day

CPA 24

Prevention of mother to child transmission of HIV

PMTCT: newborn from an HIV+ mother put under ARV protocol

7-377 192 Average value selected


CPA 25

Curative consultation with doctor in hospital

Treat severe malaria in children 87 101 Average value selected

Jha, P., O. Bangoura, and K. ranson. 1998. "The cost-effectiveness of forty health interventiones in Guinea." Health Policy and Planning no. 13

Treat severe diarrhea in children 74 Ibid Treat severe pneumonia in

children 31 Ibid

Treat severe pneumonia in adults 213 Ibid CPA 26

Cesarean section 4 11 Average value selected

Hounton, S., D. Newlands, N. Meda and V. De Brouwere (2009) A cost-effectiveness study of caesarean-section deliveries by clinical officers, general practitioners and obstetricians in Burkina Faso. Human Resources for Health.

CPA 18 Jha, P., O. Bangoura, and K.

102




Comment

Source

27 ranson. 1998. "The cost-effectiveness of forty health interventiones in Guinea." Health Policy and Planning no. 13

CPA 28

Major surgery 178 178 Jha, P., O. Bangoura, and K. ranson. 1998. "The cost-effectiveness of forty health interventiones in Guinea." Health Policy and Planning no. 13

CPA 29

ARV Treatment 194-620 407 Average value selected

Granich, R., J. G. Kahn, R. Bennett, C. B. Holmes, N. Garg, C. Serenata, M. L. Sabin, C. Makhlouf-Obermeyer, C. De Filippo Mack, P. Williams, L. Jones, C. Smyth, K. A. Kutch, L. Ying-Ru, M. Vitoria, Y. Souteyrand, S. Crowley, E. L. Korenromp, and B. G. Williams. 2012. "Expanding ART for treatment and prevention of HIV in South Africa: estimated cost and cost-effectiveness 2011-2050.

CPA 30

Treatment of tuberculosis

43 43 Jha, P., O. Bangoura, and K. ranson. 1998. "The cost-effectiveness of forty health

103




Comment

Source

interventiones in Guinea." Health Policy and Planning no. 13

104

Financial evaluation 13. This section presents a preliminary financial evaluation of project sub-components 1.1. It seeks to answer the following three questions:

(a) What is the magnitude of the bonuses the project will pay that is consistent with the amount of financing envisioned for these two-subcomponents?

(b) Considering that the project seeks to promote more quantity and better quality services for the poor and the nonpoor through these sub-components, how much financing will be required from government over the project’s five year life to pay for the portion of the recurrent costs of services which is not covered by user fees? Knowing these financing needs and ensuring that government comes up with this required financing is indispensable for the success of this project.

(c) Is the amount estimated under point (b) compatible with the recently observed magnitude and trend in government spending for health services in public facilities?

14.Figure 1 below depicts the four financing components related to the project. The top section represents project financing of bonuses to health care providers for delivery of health services to the poor. The section right below it represents project financing of bonuses to the providers for services delivered to nonpoor beneficiaries. The portion below it is the financing of services from OOP payments by project beneficiaries. These payments will come mostly from nonpoor beneficiaries but if the bonus for the poor is insufficient to fully cover the portion of the services costs not covered by government, then the poor will also have to make some OOP payments, albeit smaller than those made by the nonpoor. Finally, the bottom segment of the figure represents the amount of financing that will be required of government to pay for the recurrent costs of the services delivered through the project. The area below the dashed horizontal line represents the amount of financing government would have in the absence of the project. But since the project will promote greater utilization of services, it is expected that government will have to come up with additional financing, beyond that currently spent in the baseline year, to pay for the recurrent cost associated with the additional volume of services delivered by the project. That amount is represented by the dark area that lies above the dashed horizontal line.

105

Figure 2: The challenge of estimating the future financing needs of health services included in the project

Magnitude of the PBF bonuses 15. The magnitude of the bonuses to be paid will depend on (1) the financing available for project sub-components 1.1, (2) the number and income level of project beneficiaries, (3) the kinds of services to be financed, and (4) the current and projected volume of services that will be subject to a PBF bonus in health centers and hospitals.

1. Amount of financing available

16. Project financing for sub-component 1.1 is US$87.5 million over five years (see Table 7).

106

Table 7: Components and sub-components of HSSP II project and associated financing (US$ and FCFA)

Project total cost Total cost (US$) Total cost (FCFA )Component 1: Improvement of utilization and quality of health services at health facilities through Performance-Based Financing (PBF) 107,500,000 52,212,750,000

Subcomponent 1.1: Performance payments to health facilities 87,500,000 42,498,750,000 Subcomponent 1.2: Governance, purchasing, coaching and strengthening health administration through Performance-Based Financing 20,000,000 9,714,000,000

Component 2: Strengthening Health Financing and Health Policy Capabilities 12,500,000 6,071,250,000

Sub-component 2.1: Introducing fee-waivers for the poor and fee exemptions for selected services 4,500,000 2,185,650,000 Sub-Component 2.2: Capacity building in health policy and management 3,500,000 1,699,950,000 Sub-component 2.3: Health Sector Monitoring and Evaluation (M&E) Strengthening 4,500,000 2,185,650,000

Source: The World Bank (2013).

2. Number and income level of project beneficiaries

17. The project will be implemented in seven departments where 3.7 million Congolese live, accounting for 91 percent of the country’s total population of 4.1 million (see Table 8). The population of these departments has been broken down into age and gender groups for matching with health services which the project will finance and which are targeted to specific population groups. The age and gender structure of the population was assumed the same in all departments.

107

Table 8 : Population total and by age and gender groups in project departments

Department

Project beneficiaries

(a)

Age structure (b)

Children under 5

Children under

15*

Adult males (16 or over)

Adult females

(16 or over)

Pregnant women

(c)Percent

Brazzaville 100.0 17.5 43.8 26.3 29.9 4.1Pointe Noire 100.0 17.5 43.8 26.3 29.9 4.1Bouenza 100.0 17.5 43.8 26.3 29.9 4.1Cuvette 100.0 17.5 43.8 26.3 29.9 4.1Niari 100.0 17.5 43.8 26.3 29.9 4.1Pool 100.0 17.5 43.8 26.3 29.9 4.1Plateau 100.0 17.5 43.8 26.3 29.9 4.1Total 100.0 17.5 43.8 26.3 29.9 4.1

Number of beneficiaries Brazzaville 1,621,713 283,800 710,310 426,902 484,500 67,139Pointe Noire 844,679 147,819 369,969 222,355 252,355 34,970Bouenza 364,959 63,868 159,852 96,072 109,035 15,109Cuvette 184,259 32,245 80,705 48,505 55,049 7,628Niari 273,089 47,791 119,613 71,888 81,588 11,306Pool 279,375 48,891 122,366 73,543 83,466 11,566Plateau 206,160 36,078 90,298 54,270 61,592 8,535

Total 3,774,234 660,491 1,653,114 993,535 1,127,584 156,253* Contains the category Children under 5. Sources: (a) Ministry of Health and Population (2013). (b) CNSEE and ICF International (2012). (c) CNSEE and ICF International (2012); Gross birth rate of 4.14 percent 18. As noted, the project will pay a higher bonus for services delivered to the poor that for those delivered to nonpoor patients. The bonus for poor patients will have to be high enough to cover a sizable part of the amount of money that poor patients currently have to finance OOP. To determine the bonus for services rendered to the poor it is necessary first to know the size of project’s target population of poor beneficiaries. 19. According to the most recently available poverty assessment report, 42.8 percent of ROC’s population lives in poverty, or below the official poverty line (CNSEE 2012). But the prevalence of poverty varies markedly across the country’s departments, as in shown in the third column of Table 9. For example, nearly three-fourths of the population of the departments of Cuvette and Plateau is poor, whereas only around one-fourth of the population of the mostly urban Brazzaville and Pointe Noire is poor. The total population below the poverty line in these seven project departments was about 1.62 million people, as shown in column four of the table. The fifth column shows the percentage of the poor population living in each department with respect to the total population in poverty in all project departments. For example, the 476,784 poor people from Brazzaville represent 29.5 percent of the poor in all seven departments.

108

Table 9: Project beneficiaries and population in poverty (n total and by age and gender groups) in project departments, 2011

Department

Project beneficiari

es

Project beneficiari

es (%)

Population in

poverty (%) (a)

Population in

poverty

Population in

poverty / Total

population in

poverty

Poorest 20% of

population (project

beneficiaries)

Poorest 20% of

population / Project

beneficiaries

Brazzaville 1,621,713 43.0% 29.4% 476,784 29.5% 222,737 13.7%Pointe Noire 844,679 22.4% 25.5% 215,393 13.3% 100,625 11.9%Bouenza 364,959 9.7% 69.4% 253,282 15.7% 118,325 32.4%Cuvette 184,259 4.9% 73.1% 134,693 8.3% 62,924 34.1%Niari 273,089 7.2% 66.6% 181,877 11.3% 84,967 31.1%Pool 279,375 7.4% 71.8% 200,591 12.4% 93,710 33.5%Plateau 206,160 5.5% 74.3% 153,177 9.5% 71,559 34.7%

Total 3,774,234 100.0% 42.8%1,615,79

7 100.0% 754,847 20.0%Source: (a) CNSEE (2012). 20. The following table presents the project’s target population living in poverty in the seven departments, by age and gender groups.

Table 10: Project beneficiaries living in poverty by age and gender groups in project departments 2011

Department Children under 5

Children under 15

Adult males (16

or over)

Adult females

(16 or over)

Pregnant women

(c) AllBrazzaville 38,979 97,559 58,634 66,545 9,221 222,737Pointe Noire 17,609 44,074 26,489 30,062 4,166 100,625Bouenza 20,707 51,826 31,148 35,351 4,899 118,325Cuvette 11,012 27,561 16,564 18,799 2,605 62,924Niari 14,869 37,216 22,367 25,385 3,518 84,967Pool 16,399 41,045 24,668 27,997 3,880 93,710Plateau 12,523 31,343 18,837 21,379 2,963 71,559Total 132,098 330,623 198,707 225,517 31,251 754,847 21. It is presumed that project will not have enough resources to subsidize all of the poor in these seven departments. Thus, it was assumed that it will seek to offer bonus subsidies for only the bottom quintile of the beneficiary population, or the 20 percent poorest. That amounts to 754,847 people (20 percent of 3,773,234) and is equivalent to only about 47 percent of the 1.62 people in poverty. This target population of poor beneficiaries was distributed across the seven departments in proportion to the share of the population in poverty of each department with respect to the total

109

poor population. Thus, for example, 12.4 percent of Pool’s department is officially poor. The target poor population for the project in Pool was therefore obtained multiplying 754,847 times 12.4 percent.

3. Services to be financed by the project

22. As already mentioned, the project will include 23 curative and preventive ambulatory services for mothers, children, and adults that are delivered in health centers (CSI); and 18 services that are delivered in hospitals. These services were selected among two larger lists, or benefits packages, formulated under a previous project in ROC (Cordaid Project No date). 23. To simplify the financial analysis, the 41 services contained in Table 11 were classified into two groups (MPA and CPA) and into three subgroups within each group, for a total of five categories. Within each group, the three subgroups were constructed to form set of services that are of approximately the same unit cost, as follows:

Table 11: Groups and subgroups of health services to be financed under sub-components 1.1 and 2.1

Group

Level and type of facility where

services are provided Subgroup Symbol Services in subgroup

MPA (Minimum package of Activities)

Ambulatory in CSI health centers

A Preventive MPA-A

Preventive consultations for mothers and children

B Curative MPA-B


C High cost MPA-C

Deliveries, ambulatory surgeries, and inpatient stay

CPA (Complementary package of Activities)

Inpatient in hospitals

A Low cost CPA-A

Preventive consultations for mothers and children

B Medium cost CPA-B


C High cost CPA-C Deliveries, inpatient surgeries

4. Volume of services that will be subject to a PBF bonus in health centers and hospitals

24. The Project Appraisal Document (PAD), in its section on Project Development Objectives and Results Framework, makes tentative projections about expected utilization rates for project-financed services. They are shown in Table 3. On the basis of these rates and the population in project departments, total utilization of project health services were made and are shown in detail in the upper part and in the six services subgroups in the bottom part.

110

Table 13: Project Development Objectives and Results Framework

Indicator Name

Unit of Measur

e

YR0 Baseline

Cumulative Target Values (%)

Frequency

Data Source / Methodology

Responsibility for Data Collection

YR1

YR2

YR3

YR4

YR5 End Target

1 New curative consultations per capita and per year % 20% 25 30 35 40 40 (a) (b) (c)

2 Percentage of pregnant women having at least 3 antenatal care visits before delivery % 50% 53 56 59 62 65 (a) (b) (c)

3 Percentage of Children fully Immunized % 47% 48 49 50 52 55 (a) (b) (c)

4 Percentage of children aged between 6 months and 59 months receiving nutritional services % 25% 34 43 52 61 70 (a) (b) (c)

5 Number of new acceptors of modern contraceptive methods % 11% 13 14 16 18 20 (a) (b) (c)

6 Number of pregnant women receiving antenatal care during a visit to a health provider (WB Core Indicator) % 50% 53 56 59 62 65 (a)

7 Percentage of pregnant women who received two doses of IPT % 15% 18 22 25 28 32 (a) (b) (c)

8 Percentage of Pregnant women counselled and tested for HIV % 10% 12 13 28 30 32 (a) (b) (c)

9 Number of Children Immunized[2] (WB Core Indicator) % 47% 49 50 52 53 55 (a) (b) (c)

10

Deliveries attended by a health professional % 30% 33 36 39 42 45

11 Admission days

% increase 2 2 2 2 2

(a) Quarterly. (b) HMIS and PBF database. (c) MOHPP/SIS.

Source: The World Bank (2013).

111

25. Wether or not project and government resources will suffice to finance these volumes of services over the project’s five year life will depend on the recurrent unit costs of the services and the magnitude of the bonuses that the project will pay under sub-component 1.1. Thus, the following section estimates the recurrent unit costs of project services.

5. Recurrent unit costs and total costs to be financed by the project

26. The starting point to estimate unit costs of government provided health services in health centers and hospitals is the government’s executed budget, shown below in Table 10. In real terms, MOH spending fluctuated widely in the period 2007-2012. It increased by 24 percent from 2007 to 2008, then in 2009, as a consequence of the Great Depression, it fell by 48 percent. In 2010, it increased by 67 percent, exceeding its 2007 value but remaining below the pre-crisis value. In 2011, it went up by 41 percent to reach its highest value to date. In 2012, it increased again in an important way (by 79 percent) because government declared 2012 to be the year of health. Actual spending in 2013 is not yet known, but the 2013 budget was 17 percent below actual spending the year before.

Table 10: Government’s budget execution for the Ministry of Health, 2007-2012 (millions of FCFA of Dec. 2012)

2007 2008 2009 2010 2011 2012 2013 (budget)Personnel 14,992 19,538 9,484 16,506 15,181 31,214 25,171Goods and services 26,873 23,443 30,642 29,619Transfers n.a. n.a. n.a. 22,095 25,058 36,914 39,843Subtotal Goods and services + Transfers 51,087 58,255 24,637 65,473 63,683 98,769 94,634Investment 11,007 44,101 94,134 65,336Program Implementing Partners (including Heavily Indebted Poor Countries, HIPC) 5,600 10,777 11,771 -- -- -- --Total 71,679 88,570 45,891 76,480 107,784 192,903 159,969Source: World Bank (2013). Project Appraisal Document. n.a.: Not available --: Not applicable 26. The following figure shows the MOH’s annual budget, its executed budget, and the rate of execution. On a per capita basis (not shown in the figure), the real executed health budget was as follows: 19,069 FCFA in 2007; 22,848 in 2008; 11,487 in 2009; 18,601 in 2010; and 25,509 in 2011.

112

Figure 3: ROC: Government Ministry of Health budget and budget execution (millions of FCFA of Dec. 2012 and percent)

Source: World Bank (2013)

27. The National Health Accounts study just completed in ROC estimated actual government and household spending in government health centers and hospitals for the years 2009 and 2010. This information is presented in Table 11. The situation observed in 2010 is used to project government and household spending in health centers and hospitals through 2013. In 2010 government spending in hospitals was 25.7 million FCFA, representing about one third (34 percent) of the total MOH’s executed budget of 76.5 million of FCFA. Government spending in health centers was 6.9 million FCFA and represented 9 percent of the MOH’s total executed budget. Household spending in government hospitals was 11.0 million FCFA, amounting to 43 percent of government spending in hospitals while household spending in government health centers was 2.8 million FCFA or 40 percent of government spending in health centers. These four spending shares just mentioned were assumed constant through 2013 to project government and household spending in hospitals and health centers in the period 2011-2013.

94,002

112,581

107,397

97,307

119,712

192,903

159,969

71,679

88,570

45,891

76,480

107,784

76.3%78.7%

42.7%

78.6%

90.0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

-

50,000

100,000

150,000

200,000

250,000

300,000

2007 2008 2009 2010 2011 2012 2013

Ex

ec

uti

on

(p

erc

en

t)

Bu

dg

et

(mil

lion

of

FC

FA o

f D

ec. 2

012

)

Budget MOH (million FCFA Dec. 2012) Execution MOH (million FCFA Dec. 2012) Execution rate (%)

113

Table 11 : Government and household spending in government health centers and hospitals, 2009-2013 (millions of FCFA of Dec. 2012)

Spending in Millions of FCFA of Dec. 2012

Actual Projected 2009 2010 2011 2012 2013 (a)

Government spending Hospitals 20,423 25,723 36,252 64,880 53,804Percent of total executed MOH budget 45% 34% 34% 34% 34%Health centers 2,259 6,911 9,740 17,431 14,455Percent of total executed MOH budget 5% 9% 9% 9% 9%

Household spending Hospitals 10,776 11,090 15,629 27,972 23,196Percent of total executed MOH hospitals budget 53% 43% 43% 43% 43%Health centers 2,685 2,763 3,894 6,969 5,779Percent of total executed MOH health center budget 119% 40% 40% 40% 40%

Total executed MOH budget 45,891 76,480 107,784 192,903 159,969The figures shown for 2013 correspond to the budget because the executed budget figures are not yet known.

Table 12 : Utilization of health services by poor and nonpoor beneficiaries of the project, baseline and project life

Utilization by the poor

Utilization by the nonpoor

28. The next task to infer the unit costs of government health services in ROC is to relate the spending figures of Table 12 with the utilization figures of Table 10.

Services n subsequent years YR1 YR2 YR3 YR4 YR5 End Target Fully immunized children 46,594 47,555 48,546 49,537 51,518 54,491

Nutritional services for children aged 6 to 59 months 24,403 33,393 42,383 51,372 60,362 69,352 Curative consultations for children and adults 168,204 212,301 254,761 297,221 339,681 339,681 New acceptors of modern contraceptive methods 33,828 39,789 45,750 51,711 57,672 63,634 Antenatal care visits for pregnant women 51,829 54,938 58,048 61,158 64,267 67,377 Pregnant women receiving two doses of Intermittent pre 5,836 7,003 8,560 9,727 10,894 12,450 Pregnant women receiving HIV counselling and testing 2,340 2,740 3,121 6,563 7,031 7,500 Deliveries 3,693 4,062 4,432 4,801 5,170 5,540 Admission day (Health center) 3,074 3,135 3,198 3,262 3,327 3,394

Admission day (Hospital) 15,370 15,677 15,991 16,311 16,637 16,970 New curative consultation (Hospital) 16,820 18,502 20,184 21,867 23,549 25,231 Deliveries (Hospital) 18,982 20,880 22,778 24,676 26,574 28,473

Fully immunized children 264,035 269,480 275,094 280,709 291,937 308,780 Nutritional services for children aged 6 to 59 months 138,285 189,226 240,168 291,109 342,051 392,992

Curative consultations for children and adults 953,156 1,203,037 1,443,645 1,684,252 1,924,859 1,924,859 New acceptors of modern contraceptive methods 191,689 225,470 259,250 293,030 326,810 360,590 Antenatal care visits for pregnant women 293,695 311,317 328,939 346,560 364,182 381,804 Pregnant women receiving two doses of Intermittent pre 33,071 39,685 48,504 55,118 61,733 70,551 Pregnant women receiving HIV counselling and testing 13,260 15,524 17,683 37,188 39,845 42,501 Deliveries 20,927 23,020 25,113 27,205 29,298 31,391 Admission day (Health center) 17,419 17,768 18,123 18,485 18,855 19,232

Admission day (Hospital) 87,096 88,838 90,615 92,427 94,275 96,161 New curative consultation (Hospital) 95,316 104,847 114,379 123,910 133,442 142,973 Deliveries (Hospital) 107,563 118,319 129,076 139,832 150,588 161,345

114

The following are the unit costs required to estimate PBF bonuses and required government spending through the project’s five year life: ACMPA-A = Average cost of health center services in subgroup A (low cost) ACMPA-B = Average cost of health center services in subgroup A (medium cost) ACMPA-C = Average cost of health center services in subgroup A (high cost) ACCPA-A = Average cost of hospital services in subgroup A (low cost) ACCPA-B = Average cost of hospital services in subgroup A (medium cost) ACCPA-C = Average cost of hospital services in subgroup A (high cost) 29. These unit costs are the six unknowns, and their values should be obtained by solving the following two spending equations, the first of government health centers and the second for government hospitals:

(ACMPA-A·QMPA-A)+(ACMPA-B·QMPA-B)+(ACMPA-C·QMPA-C)=GSHC

(ACCPA-A·QCPA-A)+(ACCPA-B·QCPA-B)+(ACCPA-C·QCPA-C)=GSHO

To solve the equations it is necessary to know the relative values of the average costs. No such information is available from ROC, and instead the findings from a study about the unit costs of health center and hospital services in Burkina Faso were used. They are briefly presented in Box 1. 30. The average costs of services obtained were obtained for ROC after solving iteratively the two equations shown above, and using the relative costs of service subgroups from the Burkina Faso study. The resulting unit costs are presented in Table 13. They were projected constant in real FCFA through the project’s life.

115

Table 13: ROC Average costs of health services per subgroups in government health centers and hospitals (XAF and UD$)

Service category

YR0 Baseline

and in subsequent

years Unit costs in XAF

MPA-A: Preventive consultations for mother and son 4,349

MPA-B: Curative consultations for adults and children 3,915

MPA-C: High cost services 14,945

CPA-A: Curative consultations for adults and children (Hospital)

5,281

CPA-B: High cost services (Hospital) 20,160

Unit costs in US$

MPA-A: Preventive consultations for mother and son 8.95

MPA-B: Curative consultations for adults and children 8.06

MPA-C: High cost services 30.77 -

CPA-A: Curative consultations for adults and children (Hospital)

10.87

CPA-B: High cost services (Hospital) 41.51

31. The average costs so obtained are such that when multiplied times the volumes of services delivered in health centers and hospitals in the baseline year (2013), they yield total costs that equal actual total costs. 32. The projected utilization of services times their unit costs yields and estimate of the total costs of health services to be delivered in government health centers and hospitals in the seven project departments. Part of those costs will be financed by government, part by patients through OOP payments, and part by the project via bonuses paid to providers.

116

Table 14: Baseline and project costs of services delivered to the poor and the nonpoor (XAF million)

Cost of services delivered to the poor

Cost of services delivered to the nonpoor

Category YR0 Baseline and iYR1 YR2 YR3 YR4 YR5 End TargetMPA-A: Preventive consultations for mother and son 681 764 847 930 1,017 1,108 MPA-B: Curative consultations for adults and children 691 869 1,043 1,227 1,400 1,408 MPA-C: High cost services 101 108 114 121 127 134

CPA-A: Curative consultations for adults and children (H 89 98 107 115 124 133 CPA-B: High cost services (Hospital) 693 737 782 826 871 916 Total 2,254 2,576 2,892 3,219 3,539 3,699 Spending in MPA 1,473 1,741 2,004 2,278 2,544 2,650 Other spending in MPA 1,279 1,512 1,740 1,978 2,209 2,301 Total spending MPA (Government + OOP) 2,752 3,253 3,744 4,255 4,753 4,951 Spending in CPA 781 835 888 942 996 1,049 Other spending in CPA 10,769 11,504 12,241 12,979 13,720 14,462 Total spending CPA (Government + OOP) 11,550 12,339 13,129 13,921 14,715 15,512 Total 14,302 15,591 16,873 18,177 19,468 20,462

MPA-A: Preventive consultations for mother and son 3,861 4,330 4,799 5,269 5,763 6,281 MPA-B: Curative consultations for adults and children 3,913 4,926 5,911 6,955 7,933 7,978 MPA-C: High cost services 573 610 646 683 720 757

CPA-A: Curative consultations for adults and children (H 503 554 604 654 705 755 CPA-B: High cost services (Hospital) 3,924 4,176 4,429 4,682 4,937 5,191 Total 12,775 14,595 16,389 18,244 20,057 20,963 Spending in MPA 8,347 9,865 11,356 12,907 14,416 15,016 Other spending in MPA 7,248 8,566 9,861 11,207 12,518 13,039 Total spending MPA (Government + OOP) 15,595 18,431 21,217 24,114 26,933 28,055 Spending in CPA 4,428 4,730 5,033 5,337 5,641 5,947 Other spending in CPA 61,022 65,188 69,364 73,550 77,746 81,952 Total spending CPA (Government + OOP) 65,450 69,919 74,397 78,887 83,387 87,899 Total 81,045 88,350 95,615 103,001 110,321 115,954

117

Box 1 Costing health care interventions at primary health facilities in Nouana, Burkina Faso

Mugisha, Kouyate et al. (2002) carried out a study of health services unit costs using a sample of four first line government health care facilities in Burkina Faso. The sources of financing in these facilities are shown in Table 15. As is also the case in ROC, government providers in Burkina Faso raised revenue from user fees and from the community, in addition to the revenue from government, and revenue from users was similar in magnitude to revenue from government sources.

Table 15 : Sources and uses of revenue used at four primary health facilities in rural Burkina Faso, 1999 in US$ (US$1 = FCFA 770)

Resources Government Health Facility

Community Total

Equipment 15,263 727 - 15,990 Recurrent revenue 4,833 20,034 - 24,867 Staff resources 14,015 4,496 1,798 20,309 Buildings 2,617 - 35 2,652 Total 36,728 25,257 1,833 63,818

Using a step-down costing approach, the authors obtained average cost estimates for eight different services provided in these facilities, as shown in Table 16. As can be seen, average costs varied in an important way. For example, the average cost of a hospitalization was 27 times greater than the average cost of a curative ambulatory visit, whereas the average cost of a well-child (or preschool) visit was about one-half that of a curative visit.

Table 16 : Resource costs and unit costs for different cost categories in US$ (US$ 1 = FCFA 770)

Cost category Unit

All cost categorie

s

Intermediate / Final

categories

Final cost categories

Amount

Percent

Unit cost

Cost weights

(outpatient visit =

1.00) Administration 16,909 Drugs & consumables 13,862 18,858 Family planning Visit 507 690 1,249 2.0% 0.51 0.17

Inpatient Hospitalization 2,756 3,750 9,613 15.1%

27.62 8.97

Outpatient Visit 10,218 13,901 22,325 35.0% 3.08 1.00 Pre-& post-natal Visit 3,739 5,087 5,087 8.0% 3.73 1.21 Health education Session 2,069 2,815 2,815 4.4% 3.16 1.03 Vaccination Dose 9,177 12,485 16,198 25.4% 1.17 0.38 Well child Visit 777 1,057 1,057 1.7% 1.65 0.54

Maternity Visit 3,803 5,174 5,472 8.6% 14.8

7 4.83

Total 63,817 63,817 63,816100.0

%

118

Figure 4 Burkina Faso: Relative unit costs of health services

Source: Mugisha, Kouyate et al. (2002).

33. The following table summarizes total health care costs in government health centers and hospitals in the seven project departments. The costs are shown separately for poor and nonpoor project beneficiaries and for the health center and hospital packages of services financed by the project.

Table 17 : Current and projected costs in government health centers and hospitals in project departments (million XAF of Dec. 2012)

34. Finally, Table 18 combines the above information about financing sources for government health centers and hospitals with the project and compares it with projected financing sources in the absence of the project. The difference is the incremental financing required because of the project. Projected financing without the project was obtained using official forecasts about the

0.17

8.97

1.00 1.21 1.03

0.38 0.54

4.83

-

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

10.00

Familyplanning

Inpatient Outpatient Pre-& post-natal

Healtheducation

Vaccination Well child Matemity

Rel

ativ

e u

nit

co

st

YR0 Baseline and in subsequent

years YR1 YR2 YR3 YR4 YR5 End TargetCost of services for the poor

MPA 1,741 2,004 2,278 2,544 2,650 CPA 835 888 942 996 1,049 Other services in health centers and hospitals not subject to PBF 13,016 13,981 14,957 15,929 16,763 Subtotal 15,591 16,873 18,177 19,468 20,462

Financing of services for the poorSubcomponent 1.1 PBF 749 840 934 1,026 1,073 Government budget 10,205 11,125 12,040 12,970 13,892 OOP payments by patients 4,466 4,833 5,206 5,576 5,861 Subtotal 15,420 16,798 18,181 19,573 20,826

Cost of services for the nonpoorMPA 9,865 11,356 12,907 14,416 15,016 CPA 4,730 5,033 5,337 5,641 5,947 Other services in health centers and hospitals not subject to PBF 73,755 79,225 84,757 90,264 94,991 Subtotal 88,350 95,615 103,001 110,321 115,954

Financing of services for the nonpoorSubcomponent 1.1 PBF 4,243 4,760 5,294 5,817 6,080 Government budget 63,042 68,227 73,499 78,724 82,743 OOP payments by patients 25,308 27,387 29,502 31,597 33,211 Subtotal 92,593 100,374 108,295 116,138 122,034

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growth of per capita GDP and keeping constant (and equal to the observed values in 2012) the share of GDP that government allocated to health centers and hospitals. 35. To support the project, government will have to contribute over its five year life an additional XAF 41.6 billion. These resources will be required to financing the recurrent costs of additional services delivered through the project above. They represent a total increase in government financing over the five years equal to about 10 percent relative to a situation in which the project is not implemented. OOP spending by households will drop by about XAF 23,100 million over the five years. That represents a 14 percent drop relative to a scenario without the project. However, PBF bonuses should help reduce almost completely user fees for poor project beneficiaries that use project-supported services and should reduce in an important way OOP spending by nonpoor beneficiaries.

Table 18: Costs without and with project and incremental costs for government, households, and the project

YR1 YR2 YR3 YR4 YR5 End TargetProjection of the financing without the project

Financing from the government 68,846 77,217 79,109 81,047 83,032 Out of pocket expenditure 29,225 32,778 33,581 34,404 35,247 PBF bonus poor - - - - - PBF bonus non poor - - - - -

Projection of the financing with the projectFinancing from the government 74,167 80,268 86,470 92,616 97,345 Out of pocket expenditure 24,782 26,621 28,480 30,330 31,918 PBF bonus poor 749 840 934 1,026 1,073 PBF bonus non poor 4,243 4,760 5,294 5,817 6,080

Incremental expenditure (million XAF)Financing from the government 5,321 3,050 7,361 11,569 14,313 Out of pocket expenditure -4,442 -6,158 -5,102 -4,074 -3,329 PBF bonus poor 749 840 934 1,026 1,073 PBF bonus non poor 4,243 4,760 5,294 5,817 6,080

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ANNEX 9: PBF IMPACT EVALUATION

REPUBLIC OF CONGO


1. Scaling-up of performance-based financing (PBF) schemes across sub-Saharan Africa (SSA) has developed rapidly over the past few years. PBF schemes have attained national coverage in Rwanda, Burundi, and Sierra Leone, and are being piloted in different sub-Saharan countries, among them: Burkina Faso, Central African Republic, Zimbabwe, Zambia, the Democratic Republic of Congo (DRC), Benin, Cameroon, Chad, and Malawi, just to name a few.

2. Initial evidence from PBF pilots in low-income countries suggests that linking payment mechanisms to defined outcomes can lead to increased service coverage and improved service quality for maternal and child health services. In Rwanda, results from two independent evaluations showed a positive impact of PBF on utilization for institutional deliveries, growth monitoring consultations, and increased levels of perceived and evaluated quality of care (Basinga et al., 2011; Meessen et al., 2007; Meessen et al., 2006). In South Kivu in the DRC, providing performance-based subsidies resulted in lower direct payments to health facilities for patients, who received comparable or higher quality services than patients receiving care in control facilities. This disparity occurred despite the fact that districts receiving performance-based subsidies received less external foreign assistance than control districts (Soeters et al., 2011).

3. A recent review points out that despite the promising results, more evidence from

rigorous experimental or quasi-experimental evaluations is needed (Gorter & Meessen, 2013; Jahn et al., 2013). They also emphasize the need of qualitative methods, in order to understand the overall system effects and the motivation and health seeking behaviour of health care providers and consumers (Witter et al., 2012; Freitheim et al., 2012).

4. In several countries, health programs are currently being developed that combine

supply-side PBF with demand-side interventions that aim at improving access to essential health services. These include linking PBF with conditional cash transfers (Zimbabwe, the Gambia and Nigeria), unconditional cash transfers (Cameroon) and community-based health insurance and pro-poor community targeting (Burkina Faso). Only a few studies have looked at the equity effects of PBF interventions. Only one study in Cambodia shows that the contracted districts outperformed the control districts in delivering MNCH services to the poor (Schwartz & Bhushan, 2004). The potential impact of PBF on equity needs to be further demonstrated.

5. The Government of the Republic of Congo aims to use evidence-based information to

decide if PBF is worthy to be extended countrywide. Component 1 will therefore include an Impact Evaluation using health facility and population-based household surveys. This Impact Evaluation is funded by a Bank-executed Trust Fund (TF) that is separate from this IDA funding and in addition to the Health Results Innovation Trust Fund (HRITF) funding of US$10 million. It is a separate HRITF grant of US$1.5 million. Below is a description of the

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objective of the Impact Evaluation and how it will be used by the Government to determine the merits of PBF.

6. Health outcomes are poor throughout the country and there exist large inequalities

within the country between urban and rural areas and different socio-economic groups. While there is a modest difference between urban and rural child mortality rates, there is a wide gap between the richest income quintile and the rest of the population.

7. An Impact Evaluation will be embedded in the phased scaling-up of PBF: The HRITF

will fund an Impact Evaluation (US$1.5 million), which will naturally fit into the phased scaling-up of PBF. The Impact Evaluation has a specific focus on the role of PBF, in combination with various demand-side interventions such as household visits for improved health-seeking behavior and targeting of the poor for improved financial access to a package of essential health services (links will be made with the World Bank LISUNGI Social Protection project ‘FY 2014). The Impact Evaluation design was finalized and validated during the project appraisal mission in October 2013.

8. The overall research question of this Impact Evaluation is “Does performance-based

financing increase utilization and quality of maternal and child health services delivered in Republic of Congo?” The primary research questions for the Impact Evaluation will be grouped into two thematic groups:

9. Equity through integrating PBF and social safety nets

a) Does PBF improve financial access to and utilization of quality health services for vulnerable populations without demand-side interventions that aim to improve financial access for the poor?

b) Does the combination of PBF and pro-poor targeting mechanisms improve financial access to and utilization of quality health services for vulnerable populations more than PBF alone?

c) Which combination of interventions provides the most value for money? 10. Behavior change through community-based PBF services

a) Does the introduction of the PBF indicator “household visit according to protocol” lead to improved preventative health behavior within targeted households, such as improved water, sanitation and hygiene, and use of bednets?

b) Does the introduction of the PBF indicator “household visit according to protocol” lead to improved maternal and child health seeking-behavior, such as use of family planning, reproductive health education for adolescent girls; antenatal and delivery services, vaccination status for pregnant women and babies?

c) Does the introduction of the PBF indicator “household visit according to protocol” lead to improved population knowledge related to maternal and child health, hygiene and sanitation?

d) Does use of the indicator “household visit according to protocol” provide more value for money than PBF without inclusion of the indicator?

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11. The effect identification will be based on a basic mean outcome comparison of treatment and control areas. To evaluate the effect of the PBF package, we will explore the random variation in timing generated by the phased-in rollout of the program across districts. The two additional interventions will be randomly rolled out within districts covered by the PBF, and can thus directly be compared to PBF only as well as to a pure control group. The study will adopt an experimental design. Randomized assignment will occur at two levels:

12. In the remaining four departments where the PBF pre-pilot has not been implemented the 20 health districts will be randomized into PBF (50 percent) and control districts (50 percent) during the first two years, followed by rolling out PBF in the remaining control districts at the end of the second year.

13. Two demand-side interventions will be introduced in the 19 districts implementing PBF

(9 in the three Departments where the PBF pre-pilot was conducted and 10 out of the 20 districts in the four new Departments) through randomized assignment at the primary care facility-level (approximately 150 primary care facilities in the 19 districts) within PBF districts to test the effects of these interventions on outcomes of interest.

14. The effect identification will be based on a basic mean outcome comparison of

treatment and control areas. To evaluate the effect of the PBF package, the IE will explore the random variation in timing generated by the phased-in rollout of the program across districts. The two additional interventions will be randomly rolled out within districts covered by the PBF, and can thus directly be compared to PBF only as well as to a pure control group.

15. Tentatively, four study groups have been defined in the concept note of the impact

evaluation as follows: a) T1: PBF with post-identification (point of service) exemptions for the poor b) T2: PBF + pro-poor targeting for improved financial access c) T3: PBF + household visits according to protocol d) C: Facilities in Year 1 control districts will receive a fixed per capita budgetary

supplement that matches the per capita budgetary allocation for T1 facilities, based on the population of the health facility catchment area.

Figure 1: Identification strategy for the PBF and demand-side interventions –

Random assignment at the health facility level in PBF districts

T1: PBF

T2: PBF + targeting for improved access for

the poor

T3: PBF + household visits according to protocol

T4:Control: fixed per capita budgetary supplement that matches the per capita

budgetary allocation for T1 facilities

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16. The Impact Evaluation will collect data on service coverage and health behaviors using household surveys, while facility surveys will be implemented for the quality indicators. Both household and facility surveys will be conducted by a third-party research firm that is not involved in any aspect of PBF implementation. 17. The IE will also have a mixed-method explanatory design: quantitative data collection will precede and inform qualitative data collection.. Quantitative data will be collected at baseline, and endline surveys. Qualitative data will be collected only for the endline survey. 18. Separate HRITF funding will cover all primary activities related to the PBF Impact Evaluation. These include data collection, data analysis and report writing, and information dissemination activities. A baseline survey will be conducted prior to the piloting of PBF in the seven targeted prefectures. Dissemination activities will include restitution of baseline and endline surveys results to key stakeholders in Congo, and peer-reviewed journal publication. 19. The baseline survey will be initiated and completed before PBF implementation begins. Survey data collection will be conducted in April-June 2014. We anticipate that the PBF implementation will begin in July-August 2014, and endline data collection will be implemented after two years in April-June 2016. Prior to beginning PBF implementation, health districts (CSS) were randomized to PBF and control study groups in a public ceremony (October 2013). Prior to implementation of PBF, health facilities in the 19 districts (CSS) implementing PBF will be randomized into one of the three treatment groups (T1, T2 and T3) during public randomization ceremonies. Since all health facilities will be sampled in the baseline random assignment to treatment or comparison groups does not need to be conducted before the baseline. The timelines was discussed and finalized with the Ministry of Health in the Republic of Congo during an impact evaluation workshop that was held in Brazzaville in October 2013. The intervention (PBF) and control districts selected during the public randomization ceremony on October 24th, 2013 are as follows:

Treatment (PBF) Control

Department District (CSS) Department District (CSS) Pointe Noire Tié-tié et

N’Goyo Pointe Noire Lumumba

Pointe Noire Mvoumvou Pointe Noire Loandjili Brazzaville Makélékélé Brazzaville Moungali Brazzaville Mfilou Brazzaville Ouénzé Brazzaville Bacongo Brazzaville Talangaï Bouenza Loutété Brazzaville Poto-Poto Bouenza Nkayi-Loudima Bouenza Madingou Pool Kindamba Bouenza Mouyondzi Cuvette Mossaka-

Loukoléla Pool Mindouli

Cuvette Owando Cuvette Alima

In addition, the nine districts (CSS) which were included in the PDSS I pilot that will also be PBF intervention group for the impact evaluation are as follows:

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Department District (CSS)

Nairi Dolisie Kibangou Mossendjo

Plateau Djambala-Lékana Gamboma Abala

Pool Kinkala-Boko Goma-Tsé-Tsé Ignié-Ngabé

21. The findings from this research project will be disseminated at the national, regional, and international level. In collaboration with the government, a final workshop will be held to discuss with all relevant stakeholders the implications of the study results in relation to the scaling-up potential of the initiative. In addition, at the end of each cycle of work, interim results will be disseminated. At the international level, dissemination will be channeled through the World Bank’s larger HRITF Impact Evaluation initiative and among the scientific and policy making community by means of a series of scientific publications in peer-reviewed journals and of oral presentations at relevant international conferences.

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ANNEX 10: HUMAN RESOURCE ASSESSMENT

REPUBLIC OF CONGO


Background and methodology 1. Congo’s health system is characterized by high morbidity and mortality rates, inadequate capacity for planning, poor motivation of health workers and systems constraints due to the inequitable distribution of health workers. Despite its poorly functioning health system, Congo is a strong economic power in the region and has the resources to improve its current health status. 2. This analysis of Human Resources for Health (HRH) is based on the most recent data from the 2011 Census Report of Human Resources for Health. The availability and reliability of the data is poor, thus limiting the scope of this analysis. After 20 years a directory of health statistics was created in 2012, thus this analysis will be unable to do a retrospective comparison of the numbers of health personnel over the past 20 years. Overall assessment objective 3. The objectives of this assessment are to: (i) assess the current status of human resources for health; (ii) evaluate the systems that support HRH planning, (recruitment, deployment, retention and training); and (iii) propose recommendations to improve the quality of essential health services delivery through better HRH management. 4. This assessment focuses on the following issues: the availability of human resources and the labor market in the country, the geographical distribution and the performance of health workers, and lastly the HRH environment. Key results and findings I. Availability of health workers 5. According to the last census of Human Resources (2011), the overall qualified human resources are sufficient. The total number of health workers in the country (public and private) is 9,737. The current World Health Organization standard is 2.28 skilled health personnel (doctors, midwives, nurses) per 1, 000 inhabitants; the Congo reaches this standard with 2.34 qualified personnel per 1,000 inhabitants. This standard is also the one utilized in the draft Development Plan of Human Resources (2012). (14,965 should equal the 4 highlighted numbers below and it doesn’t).

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Table 1: Availability of clinical qualified health workers, 2011

Estimation population 2011 *

Total clinical qualified health workers

Doctors (specialists, general practitioners, dentists) Midwives Nurses

Number of qualified health workers per 1,000 people [WHO Benchmark: 2.3]

Total 4 161 558 9737 656 1215 7866 2,34 *hypothesis demographic growth of 3% since the 2007 census Source: Report of the Census of Human Resources for Health Services, 2011 6. This generic standard on ratio of skilled health workers per population needs to be refined to the country context, the country's health care production system, the high rate of urbanization and the very low population density outside the cities of Brazzaville and Pointe-Noire (about 5 inhabitants per km2). An important part of the health personnel work at the tertiary level: a quarter of them are working in general hospitals and 10% in specialized hospitals. 7. If the overall situation seems sufficient, certain categories of staff are inadequately represented, such as pharmacists (61) or specialists who number only 200 for the entire population with some specialties being severely under-represented:

Table 2: Number and densities of clinical health cadres, 2011

Number

All clinical cadres (%)

Density (per 1,000 people)

Specialist 200 1.8% 0.05 General practitioner 323 2.8% 0.08 Pharmacist 61 0.5% 0.01 Midwife 1,215 10.6% 0.29 Professional nurse 4,524 39.6% 1.09 Associate nurse 3,342 29.3% 0.80 Dentist 40 0.4% 0.01 Health assistant 432 3.8% 0.10 Dental assistant 93 0.8% 0.02 Medical technician 14 0.1% 0.003 Laboratory technician 973 8.5% 0,23 Radio. technician 10 0.1% 0.00 Pharmacy technician 189 1.7% 0.05 Total 11,416 100% 2.74

Source: Report of the Census of Human Resources for Health Services, 2011 8. The availability of health workers and the lack of some categories of HW reflect the health worker labor market:

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Production of health workers: some specializations are not available in the country and medical and paramedical schools need to be strengthened. The Faculty of Health Sciences (FSS) is the university institution to train managers in health, human medicine, pharmacy, dentistry, human biology, public health, nursing as well as for the following specializations: cardiology, hepatogastroenterology, pediatrics, general surgery, medicaloncology, gynecology and obstetrics. The Congo has five paramedical schools (Brazzaville, Pointe-Noire, Kinkala, Dolisie, Owando) with a diverse range of training and courses for the training of midwives (only Brazzaville), nurses and health technicians. These paramedical schools are characterized by a lack of equipment and teaching materials, as well as poorly skilled trainers. In addition, there are too many students and not enough absorpative capacity to ensure proper teaching, training, and internships.

Participation of trained HR in the health marketwas marked by the interruption of recruitment (staff and contractors) in the public sector for 20 years (1986-2005). The hiring freeze has led to, the orientation of these graduates to other sectors, traveling abroad for better job opportunities and the strong development of the private health sector in the country. However, in 2005 recruitment resumed which included the recruitments of some who had graduated 10 years ago. Thus, there is a significant increase in recent years in the health workforce (public and private) after a fall in the number of health personnel in the early 2000s: from 7135 health workers in 1996, 5130 in 2002, 8050 in 2005 to 14,965 in 2011.

9. The first two waves of recruitment in 2004 and 2005 added 7,721 health workers to the public sector, but qualified clinical staff (doctors, midwives and nurses) accounted for only 30 percent of these recruitments. Regarding international migration of health personnel trained in the Congo, it was estimated that in 200632 more than 10 percent of Congolese nurses immigrated abroad. 10. Exit of the labor market: Health workers over 55 years old account for nearly 12 percent of the workforce. This means that in the next 5 years, these workers will retire. The situation is particularly worrying in the case of doctors; 20 percent of them will leave the labor market in the next five years. Recruitment in the public service which has actively been taking place since 2005 has changed the average age of the health human resources, 37 percent of them are now under 36 years old. II. Unequal distribution of health workers 11. Availability of qualified human resources countrywide hides a very uneven geographical distribution of health personnel, which results in limited access to qualified personnel in many areas. The cities of Brazzaville and Pointe-Noire constitute nearly 67 percent of Congo's population but account for 93 percent of specialists, 73 percent of GPs, 78 percent of midwives and 85 percent of pharmacists.

32 Clemens and Patterson, 2006.

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12. This unequal distribution of qualified health workers is a real problem of equity in access for rural populations. According to DHS data from 2011-2012, the departments with the worst provider to patient ratios are also those where poverty rates are the highest. The table and graphs below illustrate the unequal distribution:

Table 2 : Number and densities (per 1,000 people) of qualified health workers per region

Regions Specialists

General Practitioners Midwives Nurses

Num. Density Num. Density Num. Density Num. Density Kouilou 0 - 2 0,02 25 0,24 163 1,57Niari 5 0,019 12 0,05 52 0,20 680 2,61Lékoumou 2 0,018 2 0,02 12 0,11 229 2,11Bouenza 0 - 17 0,05 30 0,09 470 1,35Pool 1 0,004 7 0,03 46 0,17 349 1,31Plateaux 4 0,020 9 0,05 27 0,14 203 1,03Cuvette 0 - 14 0,08 34 0,19 535 3,05Cuvette-Ouest 0 - 8 0,10 8 0,10 154 1,87Sangha 0 - 7 0,07 19 0,20 99 1,03Likouala 2 0,012 9 0,05 19 0,11 173 1,00Brazzaville 150 0,097 136 0,09 647 0,42 3098 2,00Pointe-Noire 36 0,045 100 0,12 296 0,37 1713 2,13

Total 200 0,048 323 0,08 1215 0,29 7866 1,89Source: Report of the Census of Human Resources for Health Services, 2011

Figure 5: Number of inhabitants for one health worker, per department, 2011

Source: Report of the Census of Human Resources for Health Services, 2011

‐ 10,000 20,000 30,000 40,000 50,000 60,000

Pop/ 1 doctor

‐ 1,000 2,000 3,000 4,000 5,000 6,000

Brazzaville

Pointe‐Noire

Moyenne…

Kouilou

Niari

Cuvette

Pool

Sangha

Plateaux

Lékoumou

Likouala

Cuvette‐Ouest

Bouen

za

Women/1 midwife

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Unequal distribution of health workers has a direct impact on health outcomes: Figure 6 : Health outcomes (% of children fully immunized in vertical axis) and density of

nurses (per 1,000habitants in horizontal axis) per department

Source: HR census 2011 and DHS 2011

13. Several factors may explain the uneven geographical distribution of health personnel, similar to other countries in the region:

The difficult living conditions in rural areas; The absence of specific policy to encourage health workers to work in rural areas

and lack of motivation of health personnel ; Spousal reunification (although no specific provision of the public service permits

it) ; and The lack of regulation and planning for better management and allocation of

health workers. 14. Thus, it was estimated in 2006 that 60 percent of newly recruited health workers deployed in rural departments deserted their posts immediately after receiving their certificate of service. Note that a revision of the personal status of the public sector, including those of the health sector, is expected in 2013. An equivalent distance premium of 50 000 FCFA per month would be granted to staff working in rural areas. To encourage the retention of health personnel in rural areas, construction standards of health centers would include a house. Other policies currently under discussion may also help improve the availability of skilled health personnel in rural areas as the proposed public territorial function (recruitment by post). III. A low performance of health workers 14. Quality of care, partly due to the performance of health personnel, is undeniably one of the major issues in the Congo to improve health outcomes. The performance of health workers can be seen through several aspects: a lack of efficiency due to the lack of resources to implement their skills; low quality of care due to poor qualifications and inadequate behavior of health workers, lack of motivation and accountability. 15. The quality of care provided by health personnel has been widely reported as a pervasive problem in the Congolese health system. As an illustration, the results of the Intrahealth survey

Kouilou

Niari

Lékoumou

Bouenza

Pool

Plateaux

Cuvette

Cuvette‐OuestSangha

LikoualaBrazzaville

Pointe‐Noire

Congo

0

10

20

30

40

50

60

70

0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50

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in 2008 on providers' knowledge by health service shows that the average percentage of most areas of services does not exceed 50 percent in terms of quality. 16. The low quality of care is partly due to the quality and adequacy of initial as well as in service training of health personnel. For initial training, both at the Faculty of Health Sciences and paramedical schools, the quality of training is poor. There is inadequate supervision of students, limited availability of equipment and materials for training purposes and inadequacy of training/internship programs. Therefore, graduates are not able to provide a good quality of care, which may partly explain the failures and poor results of the health system. In paramedical schools, curricula are particularly unsuitable and thus fall short in teaching graduates the skills needed to excel in their profession. The shortcomings of the initial training of health personnel can be explained partly by the lack of coordination between the Ministry of Health and the Ministries in charge of training institutions (Ministry of Higher Education for FSS and Ministry of Technical and Vocational training for paramedical schools). 17. In service training for providers is essential to improve their performance and ultimately the quality of care but it is very underdeveloped in Congo. In 2010, only 1 percent of the health budget was devoted to the training of personnel. 18. The motivation of health workers also plays an important role in their performance. In Congo, the motivation of health workers is very low; according to a survey conducted in 2010 (fairly small sample), the main reasons for the poor motivation of health workers are the lack of career progress and poor wages. 19. In terms of career management since 1994 advancements were without financial rewards effects and have been much delayed. This has contributed to a significant demotivation and a decline in the purchasing power of health worker, leading to extortion practices of patients. In addition, the accountability of health workers is extremely low in the public service: ratings for grade change are unrelated to the skills and performance of agents. In addition, delays in the processing of advancement create an incentive to follow it directly inducing absenteeism, corruption and lack of motivation. IV. HRH environment 20. Average monthly salaries are quite low compared with other countries in the region and especially considering the level of wealth of Congo. In the public sector, a doctor earns in average 215 000 FCFA per month (430US$), and a nurse 105 000 FCFA (215 US$). According to the census report of 2011 human resources, 19.2% of health workers do not receive their monthly wages, including 17.3 percent of public sector staff (58 percent of unpaid personnel are nurses). 21. This low pay is linked to a wage freeze in the public service since 1984; wages began to rise in 2008. This has created a strong demotivation, the migration of some health professionals abroad and increased the number of private health facilities without quality control. Similarly, bonuses received by health workers are not related to their performance. However, the

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Government has decided to substantially increase the index point of health personnel in 2012. Health workers have begun to receive higher wages. 22. In terms of human resource management, decentralization is very limited. Management is primarily at the central level. DDS theoretically have the ability to reallocate personnel within their department, but this decision is subject to the approval of the prefect or the Ministry of Health. 23. Issues affecting the efficient management of human resources for health: First, the information system does not allow tracking and planning for HRH in the country. The lack of reliable information does not allow for a comprehensive analysis for human resources planning. The census of Human Resources for Health Services in 2011 is supposed to be the basis for building a system of computerized management of human resources. 24. Within the Ministry of Health, the creation of a dedicated Human Resources Management Unit is recent (2009-1 Decree of 12 January 2009). This new direction should play an important role in improving the planning and development of strategic plans on different aspects related to human resources (initial and in service training, forecast of needs and distribution of personnel among other HR issues). 25. In addition, various ministries are involved in the planning and management of health human resources, without effective coordination. These different structures do not communicate with each others. For instance, when it comes to initial training of health personnel, the Ministry of Higher Education is responsible for the training of doctors and the Ministry of Technical Education for paramedical training. Thus, curricula and admissions quotas are disconnected from the needs of the Ministry of Health and its strategy. Recruitment in the public service is the responsibility of the Ministry of Civil Service which determines the available positions and the Ministry of Finance that opens the budget. Again, this process is carried out without taking into account the real needs of the Ministry of Health in terms of the number and categories of personnel. To remedy this problem, a consultative framework to bring together the various actors involved in the management of HRH is being created: an Inter-ministerial Committee for Human Resources for Health. 26. Supervision of health centers and staff is quite limited because the Socio- Sanitary Districts (the teams in charge of the health district ) have very few supervisionsdue to lack of financing and adequate budgetl ( CSS does have its own budget only since 2013) and human ( both in number and in terms of qualifications) resources. 27. In terms of strategic orientation for human resources, a draft National Plan for Development of Human Resources for Health (PNDRHS) 2011-2020 (dated July 2012) exists and is based on HR census data 2011. The national plan is quite comprehensive and detailed; however, its implementation seems to have been delayed and specific action plans need to be developed. In addition, although the private health sector is absent in this PNDRH they have a strong presence in the provision of care to the population.

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Conclusions and recommendations 28. The health sector is in a reform phase in Congo. To improve the performance of the health system and the health outcomes of the population, there are several issues related to human resources. The major challenges include: The need for capacity building of institutions involved in the planning and management

of human resources; Improving performance of training schools (coaching, qualifications, curricula); Establishing appropriate mechanisms to strengthen the motivation and accountability of

health workers; and The need to develop a framework for consultation with all stakeholders (ministries,

private sector, social partners, development partners).

29. Different interventions are already underway, such as the revision of the status of health personnel, the establishment of the Human Resources Department and the establishment of an Inter-Ministerial Committee on the HRH. Several partners are also committed to the GOC on the issue of human resources (including AFD and the European Union (on initial and in service training and planning) and the World Bank. 30. The expansion and strengthening of the Results Based Financing in Congo will also play an important role in enhancing motivation, accountability and performance of health personnel. Other reforms are worth exploring further to improve the availability of human resources across the territory (territorial public status, incentives), and in the context of Congo.

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ANNEX 11: PUBLIC AND COMMUNITY INVOLVEMENT IN HEALTH

REPUBLIC OF CONGO


I. RATIONALE AND BACKGROUND FOR PUBLIC AND COMMUNITY

INVOLVEMENT 1. Public involvement: including community involvement, in the democratic public

sphere is a critical factor in the governance and service delivery of health care. Public opinion in health can be understood as the values, beliefs, prejudices, and actions of individuals and communities. The democratic public sphere represents the space between the state and individuals where free and equal citizens come together to share information, debate, discuss, and deliberate on common concerns.

2. Understanding public involvement in health care requires assessing institutional climate,

social and political structures, vulnerable people’s individual and collective assets and capabilities, as well as their values, beliefs and practices. In doing this, instruments like health care seeking behavior studies can be useful.

3. Public and community involvement in health is, therefore, consistent with notions of

fairness and democracy.33 Moreover, different policy frameworks suggest that in health, authorities and providers should plan services with communities, not only because it is morally correct - deontologism - but also because it may yield better health outcomes - consequentialism - for the communities and patients. Recent reports support consequentialism by providing empirical evidence on the use of community involvement in rendering positive outcomes in maternal and child health34, and in HIV/AIDS.35

II. PUBLIC AND COMMUNITY INVOLVEMENT IN THE DELIVERY OF HEALTH

SERVICES IN THE REPUBLIC OF CONGO (ROC) 4. ROC has a robust normative sub-legal framework supporting community participation

in the management of public health care institutions. It has created semi-autonomous organizations known as COSA (Comité de Santé) – that have a direct responsibility in the management of the primary health care institutions. (Centres de Médicine Ambulatoire et de Santé Integrale – CSI) COSAs also represent communities in the management of the referral institutions and in the highest complexity institutions.

5. Title III- « Des organes de participation de la population of Decree 96-535/1996 » (Articles 29 – 35) regulates COSAs. As this Decree concerns “the definition, classification

33 Kilpatrick, S. Multi-level rural community engagement in health. Aust J Rural Health. 2009 Feb;17(1):39 -44. 34 Bustreo, F. and Hunt P, Women and children’s health: Evidence of Impact of Human Rights. World Health Organization, 2013. 35 Rodriguez, R, et al, Investing in communities achieves results – Findings from an evaluation of community response on HIV-AIDS - World Bank Group, 2013.

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& management of health facilities”, this can be interpreted as the expectation that COSAs help improve management of health facilities.

6. Community Involvement in the management of public institutions is de jure assured at

the different levels of health care. The primary institution is the Comité de Santé. (COSA) which has a direct engagement with the primary health care facility (Centres de Médicine Ambulatoire et de Santé Intégrale - CSI) and which are expected to represent the population, without discrimination of any kind. (Art 29 – 31, Dec 96-535). Elected COSA representatives participate in the Management Committee of the District Level Hospital (Comité de Gestion pour l`Hôpital de Base – COGES, Articles 32 – 33, Dec 96-535). COSA representatives also participate in the Management Committee of the Tertiary Level Hospital (Comité de Direction – CODIR - pour l`Hôpital et le Centre Hospitalier et Universitaire, Articles 34-35, Dec 96-535).

A. Observed elements in the Republic of Congo

7. The following salient elements are based on a systematic literature research and on more than

20 interviews conducted on the field between June and July 2013.

8. The concepts of Community Participation (CP), Civil Society Organizations (CSO), Community Liaison Teams (CLT), and Comité de Santé (COSA) are well positioned in the health system, and among decision makers and the citizenship. This became evident through the different interviews and meetings since CP & COSAs were repetitively mentioned as pillars of the functioning of the health care system. When asked, citizens knew of the existence of these institutions and of their main roles and responsibilities.

9. There is limited evidence of Civil Society Organization engagement in the different

advocacy, accountability, and participatory domains of the governance of the health care system. Two notable exceptions are the Réseau National des Associations des Positifs du Congo & the Association Congolaise pour le Bien Etre Familial; the former focuses on HIV-AIDS while the latter works on Maternal & Child Health.

10. Civil Society Organizations engagement on health focuses on outpatient and inpatient

service delivery. Functioning as not-for-profit private sector, CSOs apply cost-recovery to their pricing schemes, yet, there seems to be little collaboration and coordination between them and the public sector (DDS-CSS – CSI). According to UNICEF, 50 percent of the population uses NGOs or lucrative health structures beyond public services.

11. Community Liaison Teams are specialized community outreach units that perform,

according to UNICEF, three distinguishable functions: (i) Complete Package, representing an extension of the Integrated Health Centre. They bring the information and services especially to remote areas, which are difficult to access; (ii) Promotional Package, bringing information and services mainly in urban areas, with easy access to sanitary structures. They focus on essential family practices and on increasing the service demand and use; and (iii) Distributors, ensuring the distribution of medications. They depend exclusively on the programs that make use of them.

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12. Following a categorical analytical framework (Figure 3) and using semi structured cognitive interview technique; information was gathered on the functioning of ten COSAs. (Figure 4) This framework uses four analytical categories that provide a comprehensive perspective of the individuals belonging to an organization, its institutional capacities, their relational abilities and power structures, and lastly, their specific knowledge on their core business.

Figure 3 – Analytical categories used in the assessment of COSAs

Table 3 – Interviewed Circumscriptions Socio-Sanitarie,

14. Preliminary findings question the role of COSAs as agents of the community. Evidence

of meaningful community participation was not salient throughout the interviews (see Table 4). On the contrary, COSAs primary observed role was serving in health promotion and in community outreach. In addition, COSAs managerial capacities appear low across the board, which, in part, prevents them from responding to their normative obligations. Their financial incentives are misaligned. Finally, according to UNICEF, only 26 percent of CSS in Congo dispose of functional COSAs.

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Table 4: Results of the preliminary assessment of the Health Committee

1. Individual COSA members:

• Are senior individuals between 45 & 70 years old, and they are predominantly male literate individuals. Only one COSA had female representation in its bureau (vice-president and treasurer).

• Are amongst the higher educated members of their community. Many of them were teachers, accountants, and retirees, among others.

• Hold an overall low education on health matters.

• Have been in office for several years. • Perceive themselves as representatives

of the community, and they voice “serving others” as their primary gain.

• Reputational gains vis-à-vis the community were the most evident secondary gains.

• Claim to invest between 5 & 20 hours a week on COSA related activities.

3. Relational Between CSI and COSA

• In general, there is a passive yet respectful relation between CSI and COSA. This may be the result of the lack of accountability and the focus on participation. They meet once a month

• It was not clear whether the public health priorities of COSA were aligned with those of the CSI.

• There are no clear accountability mechanisms between these two actors.

With other COSAs • With apparent positive results on their

management capacities, COSAs recently began to exchange knowledge and standards. Promoted by CSS, this exchange is highly valued by COSAs

• COSAs expressed interest in learning from international experiences on

2. Institutional Composition

• Visited COSAs had a heterogeneous formalized structure. COSAs have a central bureau and a community liaison team. The former is in charge of the management & interlocution with CSI and the latter supports community outreach.

• Having anywhere between 4 & 11 members, three positions are consistent in all Bureaus: President, Secretary General and Treasurer. The composition does not necessarily mirror Article 32 of Decree 96-535.

• The President carries the gravitas. • COSAs are elected for 2 or 3-year

period by the general assembly (GA) of the community, which is gathered solely for this purpose. However, community participation in the GA is quite low. Only the COSAs in Brazzaville provided written evidence of the Assembly and its agenda.

Operational strategy and bureau meetings

• At the beginning of the year, each COSA should lay out an Operational Plan (OP) that details the activities, indicators, and objectives.

• The existence of OPs was evident only in the COSAs-Brazzaville. During the interviews the other COSAs mentioned their OPs but failed in sharing documentation.

• De jure, OPs are followed in monthly meetings. De facto, monthly meetings do not always take place, and when they do, they may not be linked to achieving OPs objectives. Only COSAs-Brazzaville provided documented evidence of these meetings.

• Overall COSAs management capacities

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community participation With the communities

• COSAs have created and significantly used two channels of communication: General Assemblies and Community Outreach.

• COSAs claim to render visits to the community as part of their community outreach program,

• According to COSAs, communities seem uninterested in the outreach activities , either because they live in poverty or because it was hard to follow up on them

• COSAs do not effectively channel complaints on quality of care.

4. Health knowledge

• With different degrees COSAs did not seem knowledgeable on the main causes of morbidity and mortality in their communities, nor in the barriers of access to health care, or in the perceived quality of health care services. Knowledge on this area assesses the ability of COSAs to understand communities’ perceived needs, and if needed, to react accordingly. Lack of this knowledge is a worrisome situation.

• COSAs failed to provide information

on the domains of CSS outputs (i.e. number of consultations), financial situation (i.e. revenue or expenditure and medications) income, expenditures in medications), and on health services prices (i.e. price of consultations or on medications). This knowledge is indicative of COSAs meaningful basic abilities to participate, serving as agent of the community, on the management of health care facilities.

• Serving as health promoters COSAs seem to have an adequate knowledge

seemed rather weak Financial management and accountability

• COSAs income is a fixed percentage of CSS profits, ranging from 3%, in Pointe Noire to 5%, in Brazzaville and Pool Nord. There is however, no clarity as to the budgetary line item used in calculating this percentage.

• COSAs financial accountability mechanisms are quite limited. Although COSAs are required to keep track of expenditures not all COSAs provided evidence of compliance with this requirement.

• In allocating the budget, the President is the ultimate decision-maker as to the amounts and line items, in doing this there seems to be limited participation by the other Bureau members.

• Transparency in expenditures is also quite limited and oftentimes decision is made on ad hoc basis. For example, one COSA invests 80% of its monthly income in cutting lawns around the CSI.

COSAs actions on transparency, accountability and participation

• It was not evident that COSAs were performing any of the expected transparency, participation and accountability functions listed in Table X. Furthermore, only the community outreach (not the participatory) aspect of function 3 was evident.

• In reality, COSAs work as health promoters using different mechanisms:

- “We hire a person with a megaphone and we walk through the streets letting people know that they should vaccinate their children. Oftentimes, people trained in vaccination come with us to the neighborhoods”

- “We are quite concerned with unwanted teen pregnancy and we split

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on selected areas such as family planning and safe sex behaviors. However, their ability to effectively render this knowledge in favor of the community and to affect daily behaviors & health care seeking behaviors are questionable.

ourselves to promote health sexual behaviors. We go knocking from house to house”

- “After finishing mass the priest allows us to talk for another 5 minutes in order to promote healthy behaviors and to advise the community to seek health care”

• When asked about their most remarkable achievements, COSA invariably felt proud on investing their own resources to upgrade the infrastructure of CSI. Only one COSA answered they felt proud of contributing to the improvement of access to health care.

3. RECOMMENDATIONS

15. It is recommended to develop a two-prone objective in the public and community involvement strategy, as follows:

Objective 1 – To increase access and utilization of Performance Based-Financing (PBF) health care services, it would be beneficial to use targeted communications and community outreach campaigns. Objective 2: To improve the democratic public sphere in health and the public and community involvement in health. Recommendations made are as follows:

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Recommendation 1 - With the objective of improving the understanding of the status quo, it is necessary to make an assessment of the situation of all the NGOs, COSAs, CLT, and Religious leaders. This study should list and georeference them as well as determine their status, production of services, coordination with the public sector, capacity building needs, and accountability mechanisms.

Recommendation 2 - The United Nations Committee on Economic, Social and Cultural

Rights recently recommended policy and development efforts to place special attention to the following population: Pygmys, Prisoners and Women.36

Recommendation 3 - Creation of a Community Involvement Cell at the Governmental level

within the PBF project in order to coordinate, monitor and evaluate the plan to implement. Recommendations for Objective 1 – To increase access and utilization of Performance

Based-Financing (PBF) health care services using targeted communications and community outreach campaigns.

Recommendation 4 – A Knowledge Attitude and Practice (KAP), study would benefit the

knowledge base on maternal and child health including health care seeking behavior. UNICEF currently conducts a KAP on Immunization, Vitamin A, and early breast feeding. Complementarities between these two studies should be explored.

Recommendation 5 – It would be beneficial to design a community and patient information

strategy involving NGOs, COSAs and CLTs. Each of these actors should have specific roles and responsibilities paired with the appropriate incentives and mechanisms for accountability.

Recommendation 6 - It would be beneficial to design a community and patient information

and outreach strategy involving NGOs, COSAs and CLTs. Each of these actors should have specific roles and responsibilities paired with the appropriate incentives and mechanisms for accountability.

Recommendation 7 - To design a community and patient communication campaign,

involving media. Recommendations for Objective 2 – To improve the democratic public sphere in health and

the public and community involvement in health. Recommendation 8 - With the objective of improving the public involvement and the

democratic public sphere in health, it will be beneficial to develop a map of the potical context. This map should hold an emphasis on the policy design and the service delivery scenarios.

36 Observations du Comité en l'absence du rapport initial du Congo, adoptée par le Comité à sa quarante-neuvième session (Nov 2012) (http://www2.ohchr.org/english/bodies/cescr/docs/E.C.12.COG.CO.1_fr.pdf).

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Recommendation 9 - Under the Governmental coordination, to design a public involvement strategy that comprises of the following elements:

Participation – As part of a process of involvement, community members should be involved in the design, implementation, and monitoring of PBF. In doing this, games can be explored as an innovative yet effective solution.37 38

Accountability – Accountability mechanisms should deliberatively be in place for the entire array on involved actors. Attention should be given to effective administrative mechanisms to force systemic compliance and provide individual redress (access to information and services) in cases of system failure.

Non-Discrimination - The United Nations Committee on Economic, Social and Cultural Rights recently recommended policy and development efforts to place special attention to the following population: Pygmeys, Prisoners and Women39

Transparency – Improved transparency in the contracting, financing, outcomes, and pricing is encouraged along the different levels. Open data should available online but more importantly, available and accessible, for the general public. A conscious effort to deliver understandable data to the lay-man should be paid

Human Dignity - Individual complaint bodies (see “rule of law”) might also play a dignifying role for the citizenship and as an important source of information about systemic dysfunctions. Publication of systemic reports from such bodies can complement other forms of health-system monitoring mechanisms (which should be inclusive and participatory and contain indicators central to the right to health).

Empowerment – Patients and Communities should systematically receive a charter of general and human rights, an understandable list of health benefits, an understandable list of out-of-pocket prices, and an understandable description of the use of the individual complaint mechanism.

Rule of Law - Individual complaint mechanisms that citizens can access to get redress when they are not treated in accordance with the rules (regarding access to health services, quality of care). This function can be served by administrative complaint bodies of various kinds and at different levels in the health systems. M-health can play a role in developing this.

37 Nimegeer A et al Addressing the problem of rural community engagement in healthcare service design, Health Place. 2011 Jul;17(4):1004-6. 38 First Global Symposium on the Right to Health, Back to Office Report, January 2013, World Bank Institute. 39 Observations du Comité en l'absence du rapport initial du Congo, adoptée par le Comité à sa quarante-neuvième session (Nov 2012) (http://www2.ohchr.org/english/bodies/cescr/docs/E.C.12.COG.CO.1_fr.pdf).

C o n g oC o n g o

B a s i nB a s i n

BRAZZAVILLEBRAZZAVILLE

DjambalaDjambala

SibitiSibiti

ImpfondoImpfondoOuéssoOuésso

OwandoOwando

EwoEwo

KinkalaKinkala

DolisieDolisie MadingouMadingou

EpénaEpéna

BétouBétou

SembéSembé

GambomaGamboma

OkoyoOkoyo

NgabéNgabé

ZanagaZanagaMossendjoMossendjo

MossakaMossaka

SouankéSouanké

NkolaNkola

MbindaMbinda

LirangaLiranga

EtoumbiEtoumbi

NgoNgo

MakabanaMakabana

S A N G H AS A N G H A

C U V E T T EC U V E T T E

W E S T E R NW E S T E R NC U V E T T EC U V E T T E

P O O LP O O L

KOUILOUKOUILOU

BOUENZABOUENZA

L I K O U A L AL I K O U A L A

P L AT E A U XP L AT E A U X

N I A R IN I A R I

LÉKOUMOULÉKOUMOU

B a t é k éB a t é k é

P l a t e a uP l a t e a u

Epéna

Bétou

Sembé

Gamboma

Okoyo

Ngabé

Kayes

ZanagaMossendjo

Mossaka

Souanké

Nkola

Mbinda

Liranga

Etoumbi

Ngo

Makabana

Djambala

Sibiti

ImpfondoOuésso

Owando

Ewo

Pointe-Noire

Kinkala

Dolisie Madingou BRAZZAVILLE

S A N G H A

C U V E T T E

W E S T E R NC U V E T T E

P O O L

KOUILOU

BOUENZA

L I K O U A L A

P L AT E A U X

N I A R I

LÉKOUMOU

G A B O N

A N G O L A

CABINDA(ANGOLA)

C A M E R O O N

C E N T R A L A F R I C A NR E P U B L I C

DEMOCRATICREPUBLIC

OF CONGO

Niari

Nkéni

Alim

a

Kwa

Kouyou

Likouala Sangha

Ngoko

Uba

ngi

Fimi

Likouala

Congo

Congo

Ibenga

Motaba

Koui

lou

Djo

ué

Loué

ssé

Mambili Lengoué

ATLANTICOCEAN

LakeTumba

LakeMai-Ndombe

To Batouri

To Ebolowa

To Lambaréné

To Lambaréné

To Booué

To Kikwit

To Lusanga

To Matadi

To M'banza Congo

C o n g o

B a s i n

B a t é k é

P l a t e a u

4°N

2°N

0°

2°S

4°S

4°N

2°N

0°

2°S

4°S

6°S

12°E 14°E 16°E

14°E 16°E

18°E

18°E

CONGO

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0 20 40 60 80 100 Miles

100 Kilometers

IBRD 33390

SEPTEMBER 2004

CONGOSELECTED CITIES AND TOWNS

REGION CAPITALS

NATIONAL CAPITAL

RIVERS

MAIN ROADS

RAILROADS

REGION BOUNDARIES

INTERNATIONAL BOUNDARIES

This map was produced by the Map Design Unit of The World Bank. The boundaries, colors, denominations and any other information shown on this map do not imply, on the part of The World Bank Group, any judgment on the legal status of any territory, o r any endo r s emen t o r a c c e p t a n c e o f s u c h boundaries.

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