The World Bankdocuments.worldbank.org/curated/en/824431468305087652/pdf/833… · IMCI Integrated...

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Document of The World Bank FOR OFFICIAL USE ONLY Report No: 83316-TG INTERNATIONAL DEVELOPMENT ASSOCIATION PROJECT APPRAISAL DOCUMENT ON A PROPOSED GRANT IN THE AMOUNT OF SDR 9.1 MILLION (US$14.0 MILLION EQUIVALENT) TO THE REPUBLIQUE OF TOGO FOR A MATERNAL AND CHILD HEALTH AND NUTRITION SERVICES SUPPORT PROJECT January 23, 2014 AFTHW Country Department AFCW1 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 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized

Transcript of The World Bankdocuments.worldbank.org/curated/en/824431468305087652/pdf/833… · IMCI Integrated...

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Document of

The World Bank

FOR OFFICIAL USE ONLY

Report No: 83316-TG

INTERNATIONAL DEVELOPMENT ASSOCIATION

PROJECT APPRAISAL DOCUMENT

ON A

PROPOSED GRANT

IN THE AMOUNT OF SDR 9.1 MILLION (US$14.0 MILLION EQUIVALENT)

TO THE

REPUBLIQUE OF TOGO

FOR A

MATERNAL AND CHILD HEALTH AND NUTRITION SERVICES SUPPORT PROJECT

January 23, 2014

AFTHW Country Department AFCW1 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 December 31, 2013)

Currency Unit = CFAF 477 CFAF = US$1

US$1.54 = SDR 1

FISCAL YEAR January 1 – December 31

ABBREVIATIONS AND ACRONYMS

ACT Artemesinin-based combination treatment AFD Agence Francaise de Developpement (French Development Agency) ANC Antenatal Consultations

CAMEG Purchasing Center for Essential and Generic Medicines in Togo (Centrale d’Achat des Médicaments Essentiels et Génériques du Togo)

CHW Community Health Workers C-IMCI Community-based Approach to Integrated Management of Childhood Illnesses CPC Community-based Growth Monitoring and Promotion Program DAC Directorate of Common Affairs (Direction des Affaires Communes) DAC DAC

Designated Account Division d'Affaires Communes

DHIS DHMT

District Health Information Software District Health Management Team

DISER Directorate for Information Statistics, Studies and Research (Direction des informations, de la statistique, des études et de la recherche)

DSC Directorate for Community Health (Direction de la santé communautaire) DSF EPI EU

Directorate for Family Health (Direction de la santé familiale) Expanded Program on Immunization European Union

FM GAVI

Financial Management Global Alliance for Vaccines and Immunisation

GDP Growth Domestic Product GFATM GIS

Global Fund to fight against AIDS, Tuberculosis and Malaria Geographical Information System

GMP Growth Monitoring and Promotion GoT GTZ HIV/AIDS

Government of Togo German Technical Cooperation Human Immunodeficiency Virus Infection/Acquired Immunodeficiency Syndrome

HIS Health Information System HKI Helen Keller International

HMIS Health Management Information System IA IDA

Implementing Agency International Development Agency

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ICB International Competitive Bidding IEC Information, Education and Communication IFA Iron Folic Acids IFG General Inspection of Finance IFR Interim un-audited Financial Report IHP+ International Health Partnership IMCI Integrated Management of Childhood Illnesses IPT Intermittent Preventive Treatment IPTp Intermittent Preventive Treatment for Malaria in Pregnancy ISA International Standards on Auditing ISDS Integrated Safeguards Data Sheet ISN Interim Strategy Note IYCN KfW

Infant and Young Child Feeding practices Kreditanstalt für Wiederaufbau (German Technical Cooperation)

LCS Least Cost Selection LIC Low Income Country LLIN Long-lasting Insecticide Nets M&E Monitoring and Evaluation MCH Maternal and Child Health MDG Millennium Development Goal MHDP National Health Development Plan MICS Multiple Indicator Cluster Survey MoH MOU

Ministry of Health Memorandum of Understanding

MUAC Mid-upper Arm Circumference MWMP Medical Waste Management Plan NCB National Competitive Bidding NCD Non communicable Diseases NSP ORS

National Strategic Plan Oral Rehydration Salts

PBF Performance-based Financing PDO Project Development Objective PHU Primary Health care Unit PNDS Plan National de Développement Sanitaire, or National Health Development Plan PNLP National Malaria Control Program (Programme National de Lutte contre le Paludisme) PPA Project Preparation Advance PPR Post Procurement Review PRSP PSI

Poverty Reduction Strategy Paper Population Services International

QCBS Quality and cost based selection RBF Results based Financing RBM Roll Back Malaria RDT Rapid Diagnostic Test RFP Request for Proposal

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RHIS Routine Health Information Systems SAI Supreme Audit Institution SAM SARA SDI

Severe Acute Malnutrition Service Availability and Readiness Assessment Service Delivery Indicator

SP STI

Sulfadoxinepyrimethamine Sexually Transmitted Disease

SUN Scaling Up Nutrition TB Tuberculosis TOR UNAIDS

Terms of reference Joint United Nations Programme on HIV/AIDS

UNDP UNFPA UNICEF USAID

United Nations Development Program United Nations Population Fund United Nations Childrens’ Fund United States Agency for International Development

WA WASH

Withdrawal Applications Water, Sanitation and Hygiene

WHO World Health Organization

Regional Vice President: Makhtar Diop Country Director: Ousmane Diagana

Acting Sector Director: Tawhid Nawaz Sector Manager: Trina S. Haque

Task Team Leader: Chris Atim

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TOGO Maternal and Child Health and Nutrition Services Support Project

TABLE OF CONTENTS

Page

PAD DATA SHEET ....................................................................................................................... i

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

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

B. Sectoral and Institutional Context ................................................................................. 1

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

II. PROJECT DEVELOPMENT OBJECTIVE(S) ..................................................................7

A. PDO............................................................................................................................... 7

B. Project beneficiaries ...................................................................................................... 7

C. PDO Level Results Indicators ....................................................................................... 8

III. PROJECT DESCRIPTION ..............................................................................................9

A. Project Components ...................................................................................................... 9

B. Project Financing.......................................................................................................... 14

C. Lessons Learned and Reflected in the Project Design ................................................. 14

IV. PROJECT IMPLEMENTATION ..................................................................................15

A. Institutional and Implementation Arrangements ........................................................ 15

B. Results Monitoring and Evaluation ............................................................................ 17

C. Sustainability ................................................................................................................ 19

V. KEY RISKS AND MITIGATION MEASURES ..........................................................20

A. Risk Rating Summary .................................................................................................. 20

VI. APPRAISAL SUMMARY ....................................................................................................20

A. Economic and Financial Analysis ................................................................................ 20

B. Technical ...................................................................................................................... 21

C. Financial Management ................................................................................................ 22

D. Procurement ................................................................................................................ 23

E. Social........................................................................................................................... 23

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F. Environment (including Safeguards) .......................................................................... 24

Annex 1: Results Framework and Monitoring and Evaluation ..............................................25

Annex 2: Detailed Project Description .......................................................................................31

Annex 3: Implementation Arrangements ..................................................................................40

Annex 4: Operational Risk Assessment Framework (ORAF) .................................................54

Annex 5: Implementation Support Plan ....................................................................................59

Annex 6: Economic and Financial Analysis ..............................................................................65

Annex 7: Additional Background Analysis ...............................................................................84

Annex 8: Map ...............................................................................................................................98

.

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PAD DATA SHEET

Togo

Maternal and Child Health and Nutrition Services Support Project (P143843) PROJECT APPRAISAL DOCUMENT

.

AFRICA

AFTHW

Report No.: PAD661 .

Basic Information

Project ID EA Category Team Leader

P143843 B - Partial Assessment Chris Atim

Lending Instrument Fragile and/or Capacity Constraints [ ]

Investment Project Financing Financial Intermediaries [ ]

Series of Projects [ ]

Project Implementation Start Date Project Implementation End Date

19-Feb-2014 30-Jun-2018

Expected Effectiveness Date Expected Closing Date

01-Jun-2014 31-Oct-2018

Joint IFC

No

Sector Manager Sector Director Country Director Regional Vice President

Trina S. Haque Tawhid Nawaz Ousmane Diagana Makhtar Diop .

Borrower: Government of Togo

Responsible Agency: Ministry of Health

Contact: Dr Fantchè AWOKOU Title: Coordonnateur du Programme National de Lutte contre le Palud

Telephone No.:

22822213227 Email: [email protected]

.

Project Financing Data(in USD Million)

[ ] Loan [ ] Grant [ ] Guarantee

[ ] Credit [ X ] IDA Grant [ ] Other

Total Project Cost: 14.00 Total Bank Financing: 14.00

Financing Gap: 0.00 .

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Financing Source Amount

BORROWER/RECIPIENT 0.00

IDA Grant 14.00

Total 14.00 .

Expected Disbursements (in USD Million)

Fiscal Year

2015 2016 2017 2018 2019 0000 0000 0000 0000

Annual 2.40 2.80 4.20 4.00 0.60 0.00 0.00 0.00 0.00

Cumulative

2.40 5.20 9.40 13.40 14.00 0.00 0.00 0.00 0.00

.

Proposed Development Objective(s)

To increase utilization of selected maternal and child health and nutrition services for pregnant women and children. .

Components

Component Name Cost (USD Millions)

Improved utilization of malaria and nutrition services 10.00

Strengthening Health Monitoring and Evaluation Systems; Project Management

4.00

.

Institutional Data

Sector Board

Health, Nutrition and Population .

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 Malaria 50

Human development Health system performance 25

Human development Nutrition and food security 25

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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

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

Nomination of an M&E officer and a communication officer

01-Sep-2014

Description of Covenant

No later than three (3) months after the Effective Date, nominate a monitoring and evaluations officer and a communications officer; all with qualifications, experience, and terms of reference acceptable to the Association

Name Recurrent Due Date Frequency

Preparation of annual work plans, budget and supplemental safeguards instrument

X Yearly

Description of Covenant

No later than December 1 in each calendar year (or one month after the Project Effective Date) the Recipient shall prepare and furnish to IDA: (i) a draft annual work plan and budget for the Project (including Training and Operating Costs) for the subsequent calendar year of Project implementation; as well as (ii) any Supplemental Social and Environmental Safeguard Instruments .

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Name Recurrent Due Date Frequency

Recruitment of external auditor 01-Oct-2014

Description of Covenant

No later than four (4) months after the Effective Date, the Recipient shall recruit an external auditor, with qualifications, experience, and terms of reference satisfactory to IDA

Name Recurrent Due Date Frequency

Establishment of a computerized financial accounting system and train staff

01-Sep-2014

Description of Covenant

No later than three (3) months after the Effective Date, the Recipient shall establish, within the Project Implementation Unit, a computerized financial and accounting system satisfactory to the Association, and successfully train relevant staff in the use thereof. .

Conditions

Name Type

Recruitment and nomination of Project Implementation Unit (PIU) staff Effectiveness

Description of Condition

The Recipient has nominated a procurement officer, a financial management officer, an accountant, and recruit, in accordance with the provisions of Section III of this Schedule 2, a procurement specialist, a financial management specialist and a monitoring and evaluation specialist to the project implementation unit.

Name Type

Adoption of a Project Implementation Manual. Effectiveness

Description of Condition

The Recipient has adopted the Project Implementation Manual in accordance with Section I.C of Schedule 2 of the Grant Agreement.

Team Composition

Bank Staff

Name Title Specialization Unit

Daniele A-G. P. Jaekel Operations Analyst Operations Analyst AFTHW

Liba C. Strengerowski-Feldblyum

Operations Analyst Operations Analyst AFTN2

Nicole Hamon Language Program Assistant

Language Program Assistant

AFTHW

Meera Shekar Lead Health Specialist Lead Health Specialist AFTHW

Chris Atim Senior Health Specialist Team Lead AFTHW

Itchi Gnon Ayindo Senior Procurement Specialist

Senior Procurement Specialist

AFTPW

Mohamed Ali Kamil Senior Health Specialist Senior Health Specialist AFTHE

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Tomo Morimoto Operations Officer Operations Officer AFTHW

Esinam Hlomador-Lawson

Program Assistant Program Assistant AFMTG

John Paul Clark Sr Technical Spec. Sr Technical Spec. AFTHW

Christophe Lemiere Senior Health Specialist Senior Health Specialist AFTHW

Christine McDonald Consultant Consultant AFTHE

Paivi Koskinen-Lewis Social Development Specialist

Social Development Specialist

AFTCS

Alain Hinkati Sr Financial Management Specialist

Sr Financial Management Specialist

AFTMW

Julie Ruel Bergeron E T Consultant HDNHE

Aissatou Chipkaou Operations Analyst Operations Analyst AFTHW

Non Bank Staff

Name Title Office Phone City

.

Locations

Country First Administrative Division

Location Planned Actual Comments

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I. STRATEGIC CONTEXT

A. Country Context 1. Togo is gradually emerging from a long period of political isolation and economic stagnation, with high poverty, and growth rates below the regional average. The 1990s and the first half of the next decade were marked by socio-political disorder in which the country experienced a suspension of international cooperation, leading to a drastic reduction in public development assistance, from 11.9% of Growth Domestic Product (GDP) in 1990 to 2.5 % in 2003. Following improvements in political stability and economic reforms in more recent years, GDP growth showed a modest acceleration from 3% in 2009 to 4% in 2010 and to 5% in 2011 despite a difficult international economic environment. Economic growth rates higher than the population growth rate in 2010 and 2011 are encouraging signs of economic recovery; however, these growth figures still remain well below the regional average. While incidence of poverty decreased slightly from 62% to 59% between 2006 and 2011, the situation is still worse than the 32% figures seen in the 1980s. Poverty remains highly concentrated in rural areas where the poverty headcount is above 74%, compared to 23% in Lomé, and 45% in other urban areas. In 2011, the country was ranked 162 out of 187 countries in the UNDP Human Development Index.

B. Sectoral and Institutional Context 2. Compared to the average of other countries in its income class, Togo has a mixed performance regarding key social development indicators. The life expectancy at birth in 2010 of 63 years is better than the Low Income Country (LIC) average of 59 years. So are the key nutrition indicators, including an impressive drop in acute malnutrition from 14% to 4.8% in four years (see Table I), but these data do not tell the whole story about the evolution of different forms of malnutrition in Togo, nor do they tell the story of the performance on other key maternal and child health indicators.

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Table I: Evolution of key health outcome indicators in Togo

1988 1998 2006 2010

Low income countries (2010)

Life expectancy at birth (years) 55,0 49,0 59,8

(2000) 63,3 59

Infant mortality (per 1,000 live births) 80,5 79,7 77 78 64.7

Under-five mortality (per 1,000 live births) 158 146 123 123 99

Maternal mortality (per 100,000 live births) 640 478 510

(2005) 350

(2008) 410

(2010)

Total fertility rate 6,6 5,4 5,1

(2000) 4,1 4.1

Prevalence of stunting (%) 37,0 22,0 23,7 29,7 39

Prevalence of underweight 27,0 25,0 26,8 16,6 23

Prevalence of acute malnutrition ND 12 14,3 4,8 9.3

Prevalence of HIV (% population 15-49) 1,0

(1987) 5,9

3,3 (2005)

3,2 5.0

(2009)

Sources: MICS 3 and 4, World Bank indicators, UNAIDS report (2010), SMART (2010) and MoH data

3. Some key social development indicators are worse than the LIC average figure, and the country remains highly unlikely to achieve the Millennium Development Goals (MDGs), principally due to the lack of sufficient progress in maternal and child health outcomes. For example, infant mortality has not improved (at around 80 per thousand since 1988), and child mortality remains stagnant at 123 deaths per thousand (see Table I). This lack of progress places Togo in an unfortunately rare situation in Sub-Saharan Africa, given that many countries managed to dramatically reduce child mortality within the last five years (see Figure I), usually thanks to improvements in the quality, coverage, and access to essential maternal and child health services. In addition, while maternal mortality saw a significant decline from 510 per 100,000 live births in 2005 to 350 in 2008 (Ministry of Health data), it remains well above the MDG target of 160 by 2015. Assisted delivery also decreased, from 73% in 2003 to 60% in 2010.1,2

1 The data from Table I need to be treated with some caution, however, since they are drawn from a wide range of sources and are, consequently, not strictly comparable. 2 Regarding assisted delivery, the Ministry of Health (MoH) explained that the apparent reduction in the indicator might have had more to do with a change in definition by WHO of the staff qualified to assist delivery; in effect, according to the MoH, before 2003, trained traditional birth attendants were considered qualified to deliver children, but around 2006, the staff qualified to do so became those based in health facilities.

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Figure I: Evolution of child mortality in various countries since 2005 (Demographic and Health Survey data)

4. The long period of country isolation and political disorder resulted both in low funding and weakened performance of the health sector. As stated earlier, donor funding as a share of GDP following the period of political crisis fell to almost a fifth of its previous value. In addition, and partly as a result, weak stewardship, low planning and coordinating capacity hamper the mobilization of resources. As one glaring example of the obstacles to better stewardship, planning and coordination of the sector, the country’s health information system is fragmented across dozens of different, inconsistent and sometimes overlapping vertical systems. Limited capacities for data entry and analysis, especially at decentralized levels, create difficulties in effective monitoring of health interventions and their outcomes.

5. Provision and utilization of health services reflect the weak functioning of the health system. On the demand side, the poor quality of health care resulted in low utilization of public services. For example, approximately 50% of treatments for fever (suspected malaria), the most common reason for care seeking, are sought at the community level and from the private sector. In addition, access to health care is constrained by serious inequities, for instance between the much poorer Northern regions and the better-off South of the country. On the supply side, human resources are characterized by a significant shortage of qualified health personnel, unequal geographic distribution (75% of doctors are concentrated in the capital), low productivity of staff in the absence of performance evaluation system and incentive conditions. In addition, the quality and comprehensiveness of services are poor. For example, intermittent preventive treatment for malaria in pregnancy (IPTp) and long-lasting insecticide nets (LLINs) are frequently not available to pregnant women through routine antenatal consultations (ANC), further frustrating demand and satisfaction.

6. Malaria is the first cause of morbidity and mortality of children, and fever comprises approximately 40% of all outpatient consultations. The prevalence rate of suspected malaria is approximately 33.1% among children under five (Multiple Indicator Cluster Survey, MICS 2010). Of suspected malaria (fever) 43% were treated for malaria; however, only 9.5% were treated correctly with an effective antimalarial (artemesinin-based combination treatment or ACT). Malaria treatment with ACT is currently being scaled up and rationalized by parasitological confirmation of infection by microscopy or rapid diagnostic test

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(RDT), as approximately 42% of suspected cases are not caused by malaria parasites. This policy is being rolled out in public and private health facilities and through community interventions. As a result of large scale campaigns, household ownership of at least one LLIN stands at 56% in Togo3. The percentage of children less than five years sleeping under an insecticidal bednet increased from 4% in 2000 to 57% in 2010, indicating that those households that own LLINs are using them to protect young children. Approximately 46% of pregnant women currently sleep under an insecticidal net. Nonetheless, Togo is still far from achieving universal coverage (one net for every 1.8 persons or three nets per household) and 80% utilization by all persons at risk of malaria. The routine distribution of LLINs, essential for sustaining effective coverage levels between mass campaigns, is particularly under-resourced as priority has been given to large scale campaign-style distribution. 7. While progress in reducing acute malnutrition has been impressive, chronic malnutrition has been on a steady increase since 1998. In line with international nutrition trends, data from Togo in 2010 indicate that children’s nutritional status sees the most deterioration in the first thousand days, leveling off after 24 months. 30% of children in Togo fail to reach their linear growth potential, reflecting cumulative and long-term undernutrition and poor health from conception to 24 months. The consequences of such undernutrition cannot be recovered and have lifelong physical and cognitive consequences, both for the individual as well as the society at large. Micronutrient deficiencies, particularly anemia, persist as a major cause of maternal and child morbidity, affecting 50% of pregnant women and 52% of children under five. The high prevalence of malarial infection in Togo and its strong, bidirectional link with anemia is likely contributing to the stagnating prevalence of both of these.

8. In response to this unflattering picture of health sector performance, the Government of Togo (GoT), with the support of its partners, developed a National Health Development Plan (PNDS) for the 2012-2015 with a major focus on tackling the country’s poor performance in maternal and child health (MCH) indicators. The PNDS identified five key priority policy areas and strategies for improving the health system challenges discussed above4:

a. Reduction of maternal and new born mortality as well as reinforcing family

planning; b. Reduction of child (under five years) mortality; c. The fight against major diseases – HIV/AIDS, malaria, Tuberculosis (TB) and

other diseases, including non-communicable diseases (NCDs) and also potentially epidemic illnesses and neglected tropical diseases;

d. Promotion of health within an environment favorable to good health; and e. Improve the organization, management, and delivery of health services.

9. More specifically, to help address the first cause of child mortality and morbidity discussed above (malaria), the GoT instituted the National Strategic Plan (NSP) for

3 The next large scale campaign is planned for 2014 and will be mainly funded by Global Fund for HIV/AIDS, Tuberculosis and Malaria (GFATM). 4 The strategic priorities of the PNDS are often summarized by GoT officials as follows: reduction in maternal, neo-natal and child mortality; fight against communicable and non-communicable diseases; and health system strengthening.

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Malaria Control (2011-2015), with the objective of reducing deaths attributable to malaria to near zero by 2015, and reducing malaria cases by 75% by 2015 compared to 2000, with a major focus on prevention. In this connection, great efforts were made to acquire and distribute LLINs and to sensitize the population about their benefits, especially among the population groups most at risk, such as young children, pregnant women and the poor living in rural areas. However, it is considered that the rates of ownership and utilization of such nets (at 57% among young children in 2010) remain too low and insufficient to provide community protection to those not using LLINs. The increase in utilization of LLIN among young children is believed to have resulted in a decrease in acute malaria infections in this age group, and many children presenting fever do not have malaria, although they are likely to be treated for malaria on the basis of unconfirmed clinical diagnosis (all non-specific fevers are treated presumptively as malaria parasitological diagnosis is not available).

10. Similarly, to address the worsening problem of chronic malnutrition, the Government also set up a National Nutrition Service within the Ministry of Health (MoH)’s Directorate of Primary Health Care to work with collaborating partners to implement various nutrition activities that fall within the scope of Togo’s National Food and Nutrition Policy (2010) and the National Nutrition Strategic Plan (2012). Although some interventions, such as vitamin A supplementation and deworming, are implemented on a national scale via semi-annual campaigns, the vast majority of community-based nutrition activities is supported by the United Nations Childrens’ Fund (UNICEF) and is limited to the regions of Kara and Savanes, given the high burden of child undernutrition and poverty in these two northern regions. The focus of these community-based nutrition activities is on: (i) the promotion of optimal infant and young child feeding practices; (ii) growth monitoring and promotion; and (iii) treatment of severe acute malnutrition.

11. In March 2012, the GoT made a specific request to the World Bank for support with malaria control, including the purchase of LLINs, to help close gaps in funding from their other major partner in this area, the Global Fund for AIDS, Tuberculosis and Malaria (GFATM). The proposed project is in large part a response to that earlier request (reaffirmed during consultations for this project). The proposed project will, however, go beyond commodity purchases by also taking the opportunity to strengthen the integration of malaria control into the routine delivery of antenatal care and community-based integrated management of childhood illness (C-IMCI). Stepping up malaria control efforts within the core approaches to maternal and child health is also appropriate, given the burden of this disease as the first cause of mortality and morbidity and the settings in which it presents itself.

12. However, although the original request was for the procurement of LLINs to be distributed in large scale campaigns, it is also recognized that the country’s health challenges after a decade and a half of crisis are multi-faceted and systemic, and their solutions would also require a broader systems approach. In consultations between the Government, the Bank team and the GoT’s major health sector partners during project identification, it was agreed to use the opportunity of the Bank’s re-engagement after 15 years of absence to make a start at addressing the broader health system challenges identified during those consultations as well as in the current PNDS 2012-2015 and the Health Country Status Report of 2011. It was agreed during project preparation that a phased approach, based on

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tackling the immediate health priorities within the initially available funding and complementarity with the interventions of other partners, would be prudent.

13. Within the initially available US$14 million funding for this project, a phased approach to tackling the country’s health priorities will begin with addressing certain selected MCH and nutrition services within the GoT’s overall and broader MCH and Nutrition programs. These selected services are malaria control in pregnancy and C-IMCI, improving the chronic malnutrition situation and strengthening the dysfunctional and severely underfunded GoT’s monitoring and evaluation (M&E) system. In subsequent phases, and contingent on obtaining further funding, this engagement will expand beyond malaria and nutrition services and M&E, to tackle broader health system issues, such as human resource challenges, institutional deliveries and other aspects of the continuum of maternal care, drug and supply chain management as well as the piloting of results-based financing (RBF) approaches in MCH and Nutrition, etc.

14. The new project also builds on the increasing re-engagement of the donor community with the GoT in recent years and is in line with the latter’s MDG priorities and those laid out in various strategy and policy documents, such as the PNDS.

15. The proposed project ensures synergies and complementarity with other activities financed by the GoT and other Development Partners. The GFATM has been a primary actor in the ongoing malaria control interventions, including financing of the mass campaigns of LLINs, along with their support to tuberculosis and HIV/AIDS. In addition to mass campaigns, the GFATM also supports facility and community-based diagnosis and treatment of uncomplicated malaria and the prevention and control of malaria during pregnancy until 2015. However, at the time of project preparation, the disbursement of funds to the public sector for malaria control was delayed pending negotiations. The project will complement the already committed financing and address the immediate and urgent modest gaps (2013-2015), the anticipated major gaps in funding for malaria prevention and control for pregnant women attending ANC as well as the community-based diagnosis and treatment of malaria following the close of the GFATM project in 2015. UNICEF is also actively supporting malaria control through LLIN distribution, Information, Education and Communication (IEC) and awareness campaigns in the remote areas of the country.

16. In the area of nutrition, the partners involved are UNICEF in treatment of acute malnutrition and prevention activities of malnutrition, and Helen Keller International (HKI) which is focused on Vitamin and iron fortification of staple foods. All ongoing nutrition activities target primarily the two northern regions of Savanes and Kara with the rest of the country receiving no support.

17. The community-level approach involving community health workers (CHWs) is aligned with the Government’s national strategy of community-based interventions which aims to optimize the provision of services at community levels to enhance population’s geographical and financial access to primary health care5. The proposed project will use

5 Togo’s national health development plan (2012-2015) places as one of its priorities strengthening of community level services through scale-up of high-impact interventions using CHWs.

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community-based approaches to implement service delivery and monitoring/reporting wherever this appears more cost-effective than the alternatives, in line with current GoT policies as well as the implementation approaches of key partners supporting similar interventions in other parts of the country, especially UNICEF and GFATM implementing agencies.

18. In the area of addressing health system issues, the French Development Agency (AFD) has so far been the principal partner of the Government, with focus on two areas: human resources (training of personnel, development of a new MoH organogram and an incentive package for those deployed out of Lomé) and drug supply management (pharmaceutical sector audit, support to drug-related regulations and central drug procurement unit)6. The discussions held in the context of identifying the country’s health system priorities for this new project led to a unanimous consensus on the need for the World Bank to focus its immediate efforts in strengthening the Health Management Information Systems (HMIS) as this has been a completely neglected area despite its dysfunctional state and the high demand expressed by the GoT. A comprehensive list of partners involved in the health sector in Togo and their areas of intervention is presented in Annex 7, Table 7.4.

C. Higher Level Objective to which the Project Contributes 19. This project is fully in line with the Bank’s Global, Regional and Country-level strategies for economic development, poverty reduction and health (including World Bank’s Strategy for Africa and Second Interim Strategy Note (ISN-II) for Togo covering 2012-2013). The project is fully aligned with the third pillar of the ISN for FY12-13 which supports the government's poverty reduction efforts by improving, among others, quality and access to basic education and health services. The Health Country Status Report identified priority needs and informed current Government policies on health (such as MCH, nutrition, community health, better governance and health systems strengthening). This project also contributes to the two major goals of the World Bank (reducing extreme poverty and boosting shared prosperity) as well as to the three main planks of the World Bank strategy (focus on main challenges; solutions and leveraging of partners). Togo is also a party to international initiatives and partnerships supported and promoted by the Bank, including the MDGs 1c, 4, 5 and 6, International Health Partnerships (IHP+), Roll Back Malaria (RBM), and Scaling up Nutrition (SUN). This project will facilitate achievement of the Government’s targets associated with these initiatives.

II. PROJECT DEVELOPMENT OBJECTIVE(S) A. PDO

20. The project development objective (PDO) is to increase utilization of selected maternal and child health and nutrition services for pregnant women and children.

B. Project beneficiaries

6 In both HRH and supply chain areas, and despite the fact that it is appreciated and important, the AFD support still leaves significant gaps which need to be filled.

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21. The direct beneficiaries of the project are pregnant women who would receive malaria and nutrition services as part of a package delivered during their routine ANC visits, and children under five who would benefit from selected services of the community-based approach to the IMCI, including activities aimed at prevention of chronic undernutrition and biological confirmation of malaria using RDTs. In addition, the National Program for Malaria Control (PNLP), the National Nutrition Services as well as the HMIS Division within the MoH would benefit from an increased capacity for program management, M&E, targeting, and coordination and implementation through technical assistance. Similarly, at decentralized levels, district levels health administration, health workers at facility levels will benefit from enhanced collaboration and project management capacity. CHWs who will be key for community level activities will also receive training, supervision and goods to implement malaria and nutrition activities, thus increasing their capacity. 22. In terms of geographical coverage, the project will cover all six regions of the country for malaria-related activities, thus achieving nationwide coverage, whereas it will be limited to the two regions of Plateaux and Centrale for nutrition-related activities. These two regions were selected for project nutrition activities based on two criteria: (i) prevalence of chronic undernutrition; and (ii) complementarity with existing nutrition interventions. Currently, all nutrition activities are heavily focused on the two northern regions of Savanes and Kara, which have, respectively, the first and third highest prevalence rates of chronic undernutrition, while the Centrale and Plateaux regions have the second and fourth highest prevalence of chronic undernutrition in Togo respectively. In addition, the current coverage of routine or preventive nutrition services is very poor in these regions.

23. Overall, notwithstanding the limited resources, the project expects to reach 1,331,645 direct beneficiaries who are considered the most vulnerable group of the population, out of which 59% are women. (This figure includes pregnant women and females of age below five years).

C. PDO Level Results Indicators

24. The achievement of the above PDO will be assessed through the following key indicators:

a. Proportion of pregnant women who slept under an LLIN the previous night; b. Proportion of women who received IPT during ANC visits during their last pregnancy; c. Percentage of suspected malaria cases tested by CHW using a Rapid Diagnostic Test

(RDT); d. Proportion of infants 0 to five months (less than 180 days) of age who were exclusively

breastfed in the Plateaux and Centrale regions; and e. Percentage of pregnant women attending ANC who received 90 Iron folic acids (IFA)

tablets during their last pregnancy in the Plateaux and Centrale regions

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III. PROJECT DESCRIPTION A. Project Components

25. The proposed project aims to contribute to the GoT’s MCH and Nutrition programs by addressing some key constraints to improving MCH in Togo and, thereby, improve health outcomes for pregnant women and children in the country. It is envisaged that this is the first phase of a broader and longer term effort by the GoT and its partners to tackle the systemic constraints to improve MCH and nutrition performance in the country. As currently designed, however, the project will simply support the ongoing efforts of the Government and its partners7 to improve access to proven, cost-effective and high impact malaria control and nutritional support interventions through routine delivery of MCH services, at both the facility and community levels. 26. In terms of what the success of this project would look like: fully successful implementation over the entire project period should advance sectoral development strategies through progress made in MCH, malaria control, nutrition, and C-IMCI. In addition, the full success of the project should contribute to progress in the health sector of Togo in three key ways. First, the country’s MCH indicators would start gradually to move in the desired direction (although such gains would be modest at best in the absence of additional funding over the project period). Second, the project’s success would have created a new norm in Togo’s health sector, namely that the beneficiaries and other actors would come to have an expectation of continued availability of the project’s services (a demand side pressure for prioritization of those quality services as a result of an effective and successful supply side intervention; an example of a concrete manifestation of such success would be that pregnant women would routinely expect to receive appropriate supplies of LLINs, Sulfadoxine-pyrimethamine (SP) and IFA as part of their ANC visits). Third, the project would have created confidence and optimism among the GoT and its partners leading to broader engagement by them to address the remaining critical health system challenges facing the country.8 27.

7 Principally GFATM, UNICEF and AFD. 8 The project DO section above shows the expected number of beneficiaries of the project over four years, while the later economic and financial analyses indicate expected gains in terms of lives saved and economic/financial impact.

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Figure II: Proposed project intervention areas and their alignment with national priorities and the GoT’s health-related MDG goals*

Malaria control

Chronic malnutrition

Strengthen M&E and

Proj mgmt

(i) Reduction in maternal and neo-natal mortality

(ii) Reduction in child mortality

(iii) The fight against major diseases

(iv) Promotion of health within an environment favorable to good health

(v) Improve the organization, management, and delivery of health services.

GoT’s MDGs 1c, 4, 5, 6

Project areas identified** National priorities defined in PNDS

Higher level GoT goals involved

Text

* The proposed project would address elements of all five priority policy and strategic areas defined in the PNDS while contributing to the GoT’s higher level MDGs 1c, 4,5,6. In addition to the alignment of project areas with the national priorities, Table 7.4 in Annex 7 shows other key donors involved in those intervention areas and the gaps identified for Bank intervention. ** Arrows show policy/strategic priority or project activity to which the project intervention area contributes. None of the proposed project areas addresses the full spectrum of activities or continuum of care that are included in the PNDS policy/strategic priority shown. It is envisaged that any additional funding, together with GoT and other partner resources, would enable the country to better address the remaining areas of need.

28. The project intervention areas are formally grouped into two components, each with two sub-components. COMPONENT 1: Improved utilization of malaria and nutrition services (US$10.0 million)

Subcomponent 1.1: Support for (i) malaria control in pregnancy through provision of LLINs and SPs as part of the basic package of ANC services; (ii) community-based diagnosis and treatment of malaria; and (iii) management, supervision, and behavioral changes to ensure effective utilization (US$7.0 million)

(i) This project will address malaria in pregnancy through the provision of IPTp with

Sulfodoxinepyrimethamine (SP) and free LLINs, to pregnant women attending antenatal care (ANC). These interventions, to be conducted as part of the focused

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ANC package for all women attending ANC countrywide, aim to fill the funding gap (in complement to the financing from the GoT and the GFATM Round 9 grants 9). The distribution of LLIN to pregnant women and the provision of SP for IPTp will reduce the risk of acute malarial illness in pregnant women (all malaria infections in pregnant women are considered severe); they will also contribute to reduced anemia, overall better pregnancy outcomes, and improvements in birth weight.

(ii) The project will also address community-based diagnosis and treatment of malaria by filling the funding gap (again in complement to financing from the GoT and the GFATM Round 9 grants) for the procurement of malaria RDTs to be used by CHWs for parasitological confirmation of malaria in suspected malaria cases prior to treatment with ACTs. This is a core element of C-IMCI; as suspected, malaria is one of the most common reasons for consultation with a CHW. Community-based diagnosis using RDTs will ensure that all persons who live more than five km from a health facility and seek care for malaria are treated with antimalarials, only if the RDT result is positive.

(iii) Management strengthening, close supervision and behavior change message.

Subcomponent 1.2: Community- based10 nutrition services for pregnant women and young children under five years of age (US$3.0 million) 29. This sub-component will be geographically targeted in the Centrale and Plateaux regions and any other target region selected by the government, provided there is available funding. It will aim to provide a package of basic nutrition and selected C-IMCI services to selected target populations (pregnant women and young children under five) in these two regions that have high chronic malnutrition burden, but are not covered by support from any other donor agency, except for a national Vitamin A, deworming campaign and treatment of severe acute malnutrition in the health facilities. The basic package of services will include community-based delivery of preventive services (service delivery for IFA supplements for pregnant women, and child growth monitoring and promotion (GMP), linked to C-IMCI. The selection of the interventions in the package is based on a costing exercise to determine the most cost-effective interventions.

9 The interventions for malaria control under this project were determined based on consultations with the MoH National Malaria Control Program (PNLP) who is responsible for implementation of GoT and all other financings (including GFATM) for malaria control. Identification of activities, costing, selection of target population and mechanisms for implementation are also determined together with the PNLP in order to fill in the existing gap and to avoid duplication. While the project funding will be implemented by the MoH, there are clear mechanisms of implementation to trace how IDA funds will be channeled and differentiated d in the target population and activities. 10 “Community” is used here in its broadest sense to include services provided by facilities, CHWs and NGOs based at the community level, as opposed to the national or regional levels.

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Table 2: Summary of Components 1.1 and 1.211

Target Population Children 0-2 years Children 2-5 years Pregnant Women Component 1.1: Improved utilization of malaria services a

i. For people living >5 km from a health facility, community-based diagnosis of malaria using RDTs. If the RDT test result is positive, immediate treatment with an ACT. If RDT test result is negative, referral of non-malaria febrile patients to health facility.

ii. Management strengthening, close supervision, and behavior change communication.

i. For people living >5 km from a health facility, community-based diagnosis of malaria using RDTs. If RDT test result is positive, immediate treatment of with an ACT. If RDT test result is negative, referral of non-malaria febrile patients to health facility.

ii. Management strengthening, close supervision, and behavior change communication.

i. Malaria control via distribution of LLINs and provision of SP for IPTp.

ii. All cases of suspected malaria in pregnant women should be referred to a health facility as ALL malaria infections during pregnancy are considered severe.

iii. Management strengthening, close supervision, and behavior change communication.

Component 1.2: Community-based nutrition services for pregnant women and young children (in Centrale and Plateaux regions only) b

i. Monthly GMP, counseling on IYCN practices, provision of micronutrient powders and therapeutic zinc supplements with Oral Rehydration Salts (ORS), community management of childhood illnesses, promotion of Water, Sanitation, and Hygiene (WASH) practices, and enhancing demand for Vitamin A & deworming services provided via national program. c

ii. Monthly household visits by the CHW and member of the Groupe de Soutien à l’Allaitement Maternel to support breastfeeding and IYCN practices and demand for other nutrition/health services.d

iii. Referral of sick and

i. Referral of sick

children and children with severe and acute malnutrition (SAM) to health centers for treatment.

ii. cDemand creation for Vitamin A supplements and deworming every six months (supplied via ongoing national campaign).

i. Provision of IFA supplements to pregnant women via ANC services (Note: WHO recommends iron supplements in malaria endemic areas when malaria control activities are in-place)

11 Please see Annex 2: Detailed Project Description for more details on project components and their justifications.

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severely acutely malnourished children to health centers for treatment.

a Implemented nation-wide. b Implemented in Centrale and Plateaux only. c For villages >5km from health centers, these activities will be conducted by the CHW in the community. For villages within 5 km of health facilities, the health facility staff will conduct these activities. d Carried out in villages >5 km from the health facility.

COMPONENT 2: Strengthening Health Monitoring and Evaluation Systems; Project Management (US$4.0 million) Subcomponent 2.1: Strengthening the health monitoring and evaluation system, particularly the HMIS, including the Government’s capacity to monitor its MCH programs (US$2.6 million) 30. The M&E system of the health sector in Togo is very fragmented among the existing vertical health programs. In April 2013, the MoH conducted an evaluation of the national HMIS, using the Health Metrics Network Assessment tool which identified four strategic axes to strengthen the M&E system: i) reinforcement of institutional framework; (ii) allocation of sufficient resources; (iii) improvement of data generation and management capacity, including quality control and data analysis; and (iv) dissemination and utilization of information for an evidence-based policy. The outcomes of the assessment as well the draft HMIS strategic plan were presented during a two-day workshop organized by the MoH and the World Bank as part of project preparation.

31. The support of the project is in line with the country HMIS strategic framework and will focus on reinforcement of routine Health Information System (HIS)12 and the implementation of periodic health facility survey. The project will provide the required technical and financial assistance for the development of the HMIS system. Special emphasis will be given to skills and knowledge development of the MoH staff involved in data management processes at all levels of the health system. The project will support the MoH to reinforce the routine HIS through selection of core indicators, harmonization of data collection tools and data transmission channel, and introduction of District Health Information Software (DHIS2) as data management tool (storage, analysis and feedback report production and dissemination). A Master Health Facility list which will include essential information on health facilities, such as type, location with geographical coordinates, available staff, provided services, will be developed and regularly updated. In addition, the project will support the implementation of periodic health facility surveys required to gather additional data to assess the performance of the health system as well as of the proposed project.

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Subcomponent 2.2: Project coordination and implementation support (US$1.4 million)

32. The proposed project will also support the MoH to manage and coordinate the implementation of project activities. This will include: (i) coordination and planning; (ii) financial management and audit; (iii) procurement and support to improving supply chain management; and (iv) training and supervision, including costs related to supporting the government in its implementation of safeguards policy measures (notably the medical waste management plan or MWMP). The subcomponent will also support costs related to external experts that will support the functioning of the project implementation unit (PIU), including a Procurement Specialist, a Financial Management (FM) Specialist and an M&E specialist13, as well as operating costs, such as office and IT equipment. It will also provide relevant additional support to technical programs involved in project implementation, including PNLP, Nutrition Services, Divisions for Communal Affairs (DAC), Directorate for Community Health (DSC), Information Statistics, Studies and Research (DISER), and Family Health (DSF). In this case, the project would support only additional costs to those programs directly arising from their involvement in project implementation.

B. Project Financing 33. The project will be financed by a US$ 14.0 million equivalent IDA Grant.

Table 3: Project Cost and Financing Project Components

Project cost (US$ million)

IDA Financing % Financing

1.1 Malaria control 1.2 Nutrition Subtotal Component 1 2.1 Support to HMIS 2.2 Project Coordination and Implementation Support Subtotal Component 2 Total Costs

7.0 3.0 10.0 2.6 1.4 4.0 14.0

7.0 3.0 10.0 2.6 1.4 4.0

14.0

100% 100% 100% 100% 100%

C. Lessons Learned and Reflected in the Project Design 34. In the absence of a World Bank operation in the health sector for more than 15 years, the project builds on lessons learnt from other ongoing social sector projects in Togo, wherever possible. This includes: (i) the competence transfer arrangement similar to that of the World Bank-financed Education Project, whereby national civil servants will be selected within the MoH as Homologues to work with external experts on FM, procurement and M&E; (ii) community-based intervention for chronic undernutrition prevention which follows a similar model of the World Bank-financed Social Protection Project; and (iii) institutional arrangements for community-based activities which take into account recent projects funded by GFATM and

13 The Project Coordinator and MOH staff delegated to work as part of the PIU will be funded by the Government.

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UNICEF (particularly on the involvement of CHWs and management of community-based activities at decentralized levels)14. 35. The approach of integrating critical activities for the prevention and treatment of malaria and the prevention of malnutrition in routine ANC services as well as C-IMCI is based on demonstrated successful experiences in other countries that have been regarded as a highly effective way to improve MCH. The project’s proposed support to community-based diagnosis and treatment of malaria will facilitate rapid access to diagnosis and treatment, particularly for target groups living far from a health facility. Similarly, integrating community-based GMP activities with C-IMCI builds on successful experiences in the region, with behavior change communication strategy, particularly focusing on IYCN practices, as recommended by WHO and UNICEF. Targeting the communication and counseling efforts to the age range between conception and 24 months (also referred to as the window of opportunity for effective interventions) is also based on a consensus that the most damaging effect occurs during this age range. IV. PROJECT IMPLEMENTATION A. Institutional and Implementation Arrangements15

At the central level:

36. The proposed project will be led and coordinated by the MoH and implemented by the relevant MoH Programs and Divisions, including the PNLP, Nutrition Services, DAC, DSC, DISER and DSF. 37. A Project Monitoring Group (or Groupe de Suivi) has been established within the MoH to assume the oversight functions of this project. A Ministerial Order (Arrêté) for the creation of this Group was issued on August 22, 201316. Members will include the Ministry of Finance as well as representatives of different Programs and Divisions within the MoH, as stated in the above paragraph.

38. Day-to-day project coordination and management at the central level will be handled by the project implementation unit (PIU) being established within the MoH under the General Directorate17. The PIU will assume, among others, fiduciary management responsibilities, overall planning, internal auditing and M&E. The MoH will appoint a national Project Coordinator who will work full time on the project and will lead this team. Other members of the team will include those responsible for FM, procurement, accounting, M&E and communications, accompanied by an administrative assistant(s) and a secretary. The project aims

14 The Government is currently carrying out an evaluation of the community-based interventions in the Savanes and Kara regions with support from UNICEF. The study will highlight aspects on promotion, prevention and treatment and referrals to the health facilities, when necessary. Field data collection is currently ongoing, and a preliminary report will be available by the first quarter of 2014. 15 A graphical representation of the actors and the proposed institutional arrangements are given in Figure 3.1 in Annex 3. The roles and responsibilities of the actors are also described in Table 3.1 in the same annex. 16 Arrêté No. 130/2013/MS/CAB/DGS Portant création, attributions et composition du Groupe de suivi de la mise en oeuvre du PASMIN financé par la Banque mondiale. 17 Arrêté No. 131/2013/MS/CAB/DGS Portant création, attributions et composition de la Cellule de gestion du Projet du PASMIN financé par la Banque mondiale.

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to align with Government systems and integrate into existing structures rather than creating parallel systems; however, due to the lack of institutional memory in the MoH regarding the management of Bank projects, both the MoH and the Bank team recognized that the process of fully aligning and integrating into the existing systems would happen over the project period, with some external experts reinforcing the existing GoT capacity18. Based on a competence transfer plan for each homologue, the objective is to ensure that the national capacity is sufficiently built to take over the project activities without any external support by the third or fourth year of project implementation. This arrangement was already tested with the World Bank financed education project in Togo and has so far yielded satisfactory results. 39. The project will rely on regional and district health authorities to supervise and coordinate the activities at decentralized levels, including management of inputs, oversight of health facilities to supervise the CHW activities and pay them incentives. Under Component 2.1, they will also be responsible for data collection at decentralized levels.

40. Health facility workers will be responsible for delivering the malaria and nutrition services as described under project description. In addition, they will support the mobilization of communities and their selection of CHWs that the project will work with (from the pool of existing CHWs). The selected CHWs will be grouped by health facilities, and heads of health facilities will be responsible for supervising and reporting on these CHWs. The performance of CHWs will be verified against a set of performance criteria and based on verified reports; district health authorities will pay the CHWs19.

41. The principle of the project’s community level implementation is to support the Government’s efforts to re-organize and rationalize the system of CHWs, including their profiles, numbers, tasks, distribution and remuneration. Currently, the system is disorganized and characterized by a vertical approach, whereby partners have very different implementation mechanism of the community-based approach. Their numbers are not necessarily always related to the population size or their workloads, but often to the number of partners involved, with separate CHWs for different kinds of services/programs. The Government would like to put an end to the current system and have CHWs distributed more rationally, with each one capable of providing an integrated package of community level health services. They recognize this would take time; as a result, they would like the project to help them make a start on a pilot basis to show its feasibility.

42. It was agreed that, under Component 1, a pilot mechanism will be put in place in the two regions of the project’s nutrition interventions to support the Government’s efforts to bring some rationality to the CHW system. Concretely, this activity would provide technical support (through consultancies, training and operational cost) to the Government to: (i) reorganize their community-based interventions around an integrated package of malaria, nutrition and selected

18 These external experts will be recruited during the preparation phase of the project through a Project Preparation Advance (PPA). 19 The verification mechanism will be defined as part of the current consultations the MoH is conducting on introducing some performance incentives in the sector. It is also anticipated that the World Bank will provide an expert to assist the MoH in designing such a pilot mechanism for the two regions of the project’s nutrition interventions.

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C-IMCI services; (ii) remunerate the CHWs recruited under the financing of this project20, based on an improved mechanism to ensure more sustainability of the Government’s community-based initiatives after the project period; and (iii) review the mapping, profile, numbers and systems of supervision and monitoring of the CHWs.

43. The maximum total amount that the project will make available from the US$14 million project envelope towards CHW remuneration and associated costs would be US$1.5 million, or just over 10% of the total, and would be made available from the budget under Component 1. This amount could enable the Government to pay at least US$10 per CHW per month in the two regions, for a total of say 2,500 CHWs over the project period. The current mapping of CHWs in the two regions shows that there are 4,600 in number, at least for those that are registered. A more rational system of distribution, such as offering the payment only to those CHWs working in remote areas (more than five km from a health facility for instance21) is expected to bring those numbers involved in the project down to probably less than half of the present total. CHW supervisors would be much fewer in numbers and also be remunerated from the total envelope indicated. In addition to delivering community-based interventions for malaria control and combatting malnutrition, CHWs will also play an important role in the collection of routine health information at community level. The involvement of local NGOs will be assessed as part of the design of the community level project implementation envisaged under the project. Their main roles could potentially be to: (i) carry out activities related to social mobilization and IEC at community levels; and (ii) complement the supervision role of CHWs in areas where heads of health facilities cannot cover due to distance or workload.22 B. Results Monitoring and Evaluation

44. The availability of a functional HMIS system is essential for an effective monitoring of project progress. Therefore, the proposed project will support MoH to strengthen its HMIS system not only to make available credible data for the purpose of the project, but also to improve their capacity in monitoring the results of the overall health sector. The HMIS system to be supported under this project will include: (i) routine HMIS (including at community levels) and (ii) periodic surveys, such as Health facility surveys (see Annex 2 for further description). 45. To monitor the outcomes of the service delivery as well as the progress of the project toward the development objectives, a set of PDO and intermediate results indicators has been identified with baseline data and annual targets (See Annex 1 Results Framework). The baseline data for these indicators are identified and extracted from existing sources, such as MICS, Programs data, and HMIS reports. However, the baseline data will be revised, based on the first annual report that the PIU will produce.

20 It is expected that the CHW to be contracted under the project’s financing in the two regions of Plateaux and Centrale will be selected through a rigorous selection procedure based on a pre-determined set of selection criteria. The payment will be made against a set of performance indicators that are specified in a contract signed between the health facilities and the CHWs. Detailed mechanism will be determined as part of a TA provided at the start of this project. 21 UNICEF currently pays US$10 per person per month for CHWs, but only for those that work beyond a seven km radius of the nearest health facility, in the two northernmost regions of the country.

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46. Data will be collected at community levels and at health facility levels on a monthly basis and will ultimately reach the PIU through the district health bureau, regional bureau, program focal point and HMIS central Unit (DISER). The PIU will be responsible for the compilation, analysis and dissemination of data. The table below describes the system participants with their respective responsibilities and data flow.

Figure 3: Project data collection, reporting and management

Participants Responsibility Frequency

Quarterly

Quarterly

Monthly

Monthly

Monthly

Project Implementation Unit

Compilation, cross-checking of data accuracy and quality and production of

quarterly report

Malaria Program

Focal Point

Nutrition Program

Focal Point

Regional Health Bureau

Compilation, cross-checking of data accuracy and quality and transmission of

the report to the PIU

District Health Bureau Compilation, cross-checking of data

accuracy and quality and transmission of the Monthly report to the Regional

Health Bureau

Health Center

Data collection, including community level data, verification and elaboration of Monthly health facility report and

transmission to the Health District Bureau

DISER (MoH) Compilation, cross-checking of data accuracy and quality and Transmission of

the data to the PIU

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Monthly

C. Sustainability

47. The financial sustainability of this project will depend on many factors, such as macro trends, fiscal space for health and external funding, all of which are uncertain at this stage especially since Togo is just emerging from a period of crisis. While there has been a substantial increase in donor re-engagement with the GoT in recent years, these uncertainties could potentially be exacerbated due to: (i) the uncertainty in continued GFATM funding after 2015 for malaria-related activities23 and the absence of co-financing partners for nutrition in the two regions targeted by the Bank; and (ii) the Government contribution to community-based interventions is minimal, jeopardizing its sustainability, especially with regards to the motivation of CHWs24. The Bank team intends to address these issues as a larger discussion of health financing in the sector. The Government carried out a Health Financing Study, focused on innovative domestic financing mechanisms, and preliminary results were presented during a workshop in November 201325. This shows that the Government is seriously studying the options for domestic resource mobilization in the context of sustainability of health financing. In addition, the CHW mechanism to be put in place under the project will be integral to the overall government strategy of community-based interventions in order to ensure sustainability. 48. The outlook for institutional sustainability is more positive as the GoT has expressed its strong commitment to strengthen the Government capacity in managing donor-funded projects. The project implementation team established for the purpose of this project will be placed directly under the General Directorate of the MoH and will closely partner with the respective technical Programs and Divisions concerned. To ensure long-term capacity building, a competence transfer plan will be designed for the MoH Staff of the PIU who will receive intensive coaching by external experts in the initial years of project implementation. This knowledge transfer ensures that the skills needed to implement donor-funded projects will remain beyond the life of the project.

23 An Agreement was reached between the GoT and the GFATM with respect to the Round 9, Phase 2 grants, and disbursement that had tentatively been stopped will resume in January 2014. The grants will close at the end of 2015. Although the GoT will seek additional funding for malaria control from the GFATM, a follow-on funding is not guaranteed. Details regarding estimated gap of malaria control commodities is presented in Annex 7. 24 The current Government contribution to the CHW motivation is 81million CFA for approximately 12,000 CHWs nationwide, which translates into approximately US$1.5 per CHW per month. A large part of contribution is provided by other development partners. 25 GoT, WHO. Nov 2013. Etude sur l’exploration du potentiel d’une mobilisation des ressources domestiques par des mécanismes de financements innovants. Study presented at Hotel Eda Oba, Lomé, November 28-29 2013.

Community Health Worker

Community Health Worker

Collection of community level data, verification and transmission to the

Health center

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V. KEY RISKS AND MITIGATION MEASURES A. Risk Rating Summary

Table 4: Risk Ratings Summary Table

Risk Rating Risk Rating

Project Stakeholder Risks Project Risks

- Stakeholder Risk Moderate - Design Moderate

Implementing Agency (IA) Risks (including Fiduciary Risks)

- Social and Environmental Low

- Capacity Substantial - Program and Donor Substantial

- Governance Substantial - Delivery Monitoring and Sustainability

Substantial

Overall Implementation Risk Substantial

49. The Government commitment and interest in this new operation is strong as seen in their full involvement in the project identification and preparation phases, allowing for the project to fully align with Government priorities and other donor interventions. This could facilitate an eventual scale-up and sustainability when additional resources are mobilized. In addition, the project design ensures integration of different activities wherever possible, in order to maximize project efficiency within the current limited budget envelope. 50. Nevertheless, given the fact that a lot of preparatory activities need to be carried out in a country which experienced a long absence of World Bank-financed operations, some uncertainties remain with regards to the Government capacity to carry out this preparatory work and deliver this project within a tight timeline. In addition, the risks related to governance are difficult to assess due to the absence of historical incidence. Therefore, the overall risk is rated as Substantial.

VI. APPRAISAL SUMMARY

A. Economic and Financial Analysis

51. With the attainment of the Project Development Objective (PDO), calculations show that the total number of lives expected to be saved over the four-year project period from malaria case management alone would be 17,325, from both the under-five and over five population groups. In terms of cost-effectiveness, the estimates of direct gains from economic activities for the short and medium/long-terms show benefit-cost ratios for malaria case management that support the project on an economic ground. For example, for every US$1 invested, there is a nearly five-fold return accounting for only the short-term effects over the 4-year project horizon. This return increases to US$8.2 when life-time economic gains are

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considered, using the most conservative discount factor, and not taking into account any other economic gain.26 52. Working with the public sector is economically justified, since the project (i) focuses on high impact and cost effective interventions which are public good; (ii) generates positive externalities beyond the target beneficiaries (for example, indirect effect on siblings, change in care seeking for febrile cases, behavior change related to malaria prevention and household level nutrition practices, cognitive, and inter-generational wealth effects); (iii) addresses market failures arising from information asymmetry between the supplier and the consumer which could lead to a sub-optimal consumption of merit goods/services; (iv) contributes to reducing MCH- and malnutrition-related household financial shocks and adverse long-term and intergenerational consequences; and last, the project (v) could contribute to improved allocation efficiency and financial sustainability (for example, if the proposed community-based component reaches beneficiaries for lower unit costs, thereby reducing the annual cost of coverage and related budget requirements). 53. The experience and skills of the World Bank in designing and implementing similar projects in the health sector were recognized in the Government’s request for assistance. The Bank brings added value to this process because of its afore-mentioned skills and experience, especially in Africa as well as in other areas of the world. The World Bank’s technical support is also expected to contribute significantly to project success. B. Technical

54. MCH services constitute an integrated continuum of care that delivers essential services and interventions to women who face particular risks arising from reproduction and pregnancy, their infants at critical points, and to children in their first five years of age. The continuum of MCH care is fundamental to development which is reflected in MDGs 4 (reducing under-five child mortality by two-thirds between 1990 and 2015) and five (reducing maternal mortality by three quarters between 1990 and 2015 and achieving universal access to reproductive health by 2015). 55. Given the importance of MCH and nutrition practices as determinants of human capital and economic development, there is a global consensus on the need for introducing high-impact community-based and integrated management approaches to improve maternal and child health outcomes: The main thrust of the community-based program is behavior change, which can be implemented as a lower cost, yet effective, alternative, and which also has favorable pro-poor properties. The community-based approach aims to improve the utilization of essential services that were previously underutilized, partly, as a result of information asymmetries between consumer and provider. Given that approximately 60% of Togo’s population lives in rural areas and a significant share of communities are beyond 5 km from a facility, the

26 See Annex VI.C for more details of these calculations and key assumptions.

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community-based platform is expected to substantively contribute to coverage expansion and do this in a cost-effective manner: The strong evidence of the cost-effectiveness of C-IMCI makes this approach particularly attractive for preventing and treating malnutrition and malaria in the target population; and Last, the link between malaria during pregnancy and child nutrition (through the pathway of anemia), and the consequent adverse MCH outcomes as well as their long-term effects on households and at the macro-level make the proposed approach particularly strategic, as the effects are expected to go well beyond the sector and beyond the current time horizon. Hence, the approach is well aligned, not only with the sectoral objectives, but with the overall development and poverty reduction objectives.

C. Financial Management 56. The World Bank conducted a Financial Management (FM) capacity assessment of the PIU that is currently being established within the MoH. The PIU will be responsible for overall FM aspects, including: (i) managing the Designated Account; (ii) preparing Withdrawal Applications; and (iii) reporting. 57. The assessment was carried out in accordance with the FM Manual issued by the FM Board on March 1, 2010. It concludes that the FM arrangement necessary for the project is being established in order to satisfy the World Bank’s minimum requirements under OP/BP10.00, after which the PIU will be in a position to provide with reasonable assurance, accurate and timely information on the FM status of the project as required by the Bank. The MoH of Togo has no previous experience with IDA FM procedures, but has qualified FM officers at the central and decentralized levels that could be further trained to support the implementation of the project. In the meantime, the DAC of the ministry will handle the FM aspects of the project with the support of an FM Specialist of another IDA-financed project in the country (for example Community Development project) who will act as a mentor until an experimented FM Specialist is recruited for the project. The process of recruitment should be completed prior to project effectiveness. The FM Specialist will jointly sign payment orders with the Project Coordinator. Details of the FM for the project are included under Implementation Arrangements in Annex 3. 58. In addition to the recruitment of a FM Specialist with qualifications and experiences satisfactory to the Bank, other preparatory activities for FM will include: (i) the preparation and adoption of a FM manual for the project (to be part of the overall Procedural Manual of the project); and (ii) the set-up of accounting software. The former will be a condition of effectiveness, while the latter will need to be completed three months after effectiveness. 59. In order to mitigate fraud and corruption risks inherent to the public sector in Togo and reinforce the governance of the project, the project design incorporates regular internal audit missions to be completed by the country General Inspectorate of Finance with a strong focus on activities at decentralized levels. 60. The overall FM risk rating for the project is assessed as Substantial, but is expected to become Moderate by effectiveness, if all conditions as explained above are met.

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D. Procurement 61. A procurement capacity assessment of MoH was conducted during project preparation. The main issues identified are the lack of experience with World Bank project implementation and the absence of a procurement manual. Taking into consideration the existence of a procurement unit and an internal control committee within MoH, the overall project procurement risk has been rated Moderate. The actions to be taken to strengthen the procurement process include, inter alia: (i) the recruitment of a Procurement Specialist and nomination of a civil servant as procurement officer who must be full time devoted to the project’s procurement activities, and (ii) the preparation of the project procurement manual which will be part of the overall Procedural Manual of the project. In addition, an external expert on procurement will be recruited to strengthen the capacity of the Ministry’s staff that will be responsible for the project procurement implementation. 62. If necessary, the MoH could delegate the procurement activities related to drugs and medical supplies to Togo’s Central Drug Purchasing Agency (Centrale d’Achat des Médicaments Essentiels et Génériques du Togo (CAMEG) or to a United Nations agency, such as UNICEF, depending on the area of expertise. For example, the GoT could potentially enter into a Memorandum of Understanding (MOU) with UNICEF for the provision of at least LLIN, RDT and Anthropometric Equipment, while CAMEG could manage the procurement of SP and IFA.

63. Guidelines: Procurement for the proposed project will be carried out in accordance with; (a) the Bank “Guidelines: Procurement under IBRD Loans and IDA Credits” dated January 2011; (b) the Bank “Guidelines: Selection and Employment of Consultants by World Bank Borrowers” dated January 2011; (c) The Bank “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 (“Anti-Corruption Guidelines”).and (d) the provisions of the Grant Agreement.

64. Anti-Corruption Action Plan: The following measures will be carried out to mitigate corruption risk: • Publication of Advertisements and Contracts: All publications of advertisements and contract

awards will be done in accordance with the Guidelines requirements and published through client connection system, on external websites, i.e. UNDB and dgMarket websites;

• Debarred Firms: Appropriate attention will be given to the need to ensure that debarred firms or individuals are not given opportunities to compete for Bank-financed contracts; and

• Complaints: All complaints by bidders will be diligently addressed and monitored in consultation with the Bank.

E. Social 65. No negative social consequences are anticipated; however, various socio-cultural issues, notably social factors and traditional beliefs need to be taken into account as they determine mother and child care practices and behaviors and, subsequently, nutrition and health outcomes. The project will pay particular attention to community involvement to enhance the efficiency of conveying important messages and improve IEC. The project also anticipates the involvement of local NGOs and potentially traditional and religious bodies, if necessary, in

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beneficiary communities to pass culturally sensitive messages, including beliefs concerning pregnancy and breastfeeding. 66. The preliminary assessment by the Social Safeguards Specialist confirms that OP/BP 4.10 (Indigenous Peoples) is not triggered, given the absence of indigenous population in the project area. As the project also does not involve land acquisition leading to involuntary resettlement and/or restrictions of access to resources or livelihoods, OP 4.12 (Involuntary Resettlement) is not triggered for the project.

67. Because the project is financing LLINs, Safeguard Policy 4.09 is triggered. However, the nets to be purchased have the insecticide already affixed to the fiber of the net and are in compliance with WHO class III standards. No insecticide/pesticide will be purchased or used in the project. Therefore, the project is exempted from the preparation of a pest management plan (PMP) as per footnote 6 in Annex B of BP 4.01 (Application of EA to Projects Involving Pest Management). F. Environment (including Safeguards) 68. The project will support the Government's program and, thus, will cover the whole country for malaria and the two selected regions for nutrition. For malaria-related activities, the project will finance purchase and distribution of LLINs and RDTs. Activities related to nutrition will include nutritional supplements as well as medical test kits. The project will also finance computer and other equipment. The project will not finance any construction or any renovation. However, Safeguard policy 4.01 is triggered for the management of medical waste. Because the project does not expect any other environmental safeguard issues, a stand-alone Environmental Assessment is not required. 69. The existing Government’s Medical Waste Management Plan (MWMP) 2010-2014 was reviewed by the World Bank safeguards team and found to be a good document. However, it needed an update to: (i) include progress to date, (ii) update the document to cover the life span of the project (until mid-2018), and (iii) address the disposal of LLINs27. The Government has developed a revised MWMP and submitted it to the World Bank on October 30, 2013. The document was judged acceptable to the Bank and disclosed in country on December 4, 2013, and at InfoShop on December 10, 2013. 70. The institutional capacity for Safeguard Policies of the MoH remains to be evaluated, given the long absence of World Bank operation in the country. In this respect, the project will envisage including capacity building activities for safeguards to help implement the national MWMP and to ensure close monitoring of its progress. Some costs to support the government’s implementation of safeguards policy measures will be included as part of the monitoring and supervision costs under this project.

27 The disposal of LLINs can be addressed as an integral part of the plan, or there can be an addendum that would be separately disclosed to the public.

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Annex 1: Results Framework and Monitoring and Evaluation

TOGO: Maternal and Child Health and Nutrition Services Support Project

Table 1.1: Results Framework and Monitoring and Evaluation

PDO Project Outcome Indicators Use of Project Outcome Information

Increase the utilization of selected maternal and child health services for pregnant women and children

1. Proportion of pregnant women

who slept under an LLIN the previous night;

2. Proportion of women who received IPT during ANC visits during their last pregnancy;

3. Percentage of suspected malaria cases tested by Community Health Worker ) using a RDT;

4. Proportion of infants 0-5 months (less than 180 days) of age who were exclusively breastfed in the Plateaux and Centrale regions; and

5. Percentage of pregnant women attending ANC who received 90 IFA tablets during their last pregnancy in the Plateaux and Centrale regions.

Progress on these indicators will reflect improved access to malaria and nutrition services. It is obvious that the improved access to these specific services can be achieved through overall improvement to maternal and child health. Lack of progress will trigger an assessment of the underlying causes and performance of service providers.

Intermediate Outcomes and Outputs

Intermediate Outcome and Output Indicators

Use of Intermediate Outcome and Output Monitoring

Component 1: Improved utilization of malaria and nutrition services Subcomponent 1.1: Support for (i) malaria control in pregnancy through provision of LLINs and SPs as part of the basic package of ANC services; (ii) community-based diagnosis and treatment of malaria through IMCI; and (iii) management and supervision, as well as behavioral changes, to ensure effective utilization)

Improved utilization of malaria control services by pregnant women and children under five

6. Number of pregnant women receiving antenatal care during a visit to a health care provider (Core indicator);

7. Percentage of pregnant women who attend at least four antenatal care visits during the last pregnancy in two regions (Plateaux & Centrale); and

8. Number of LLIN distributed to pregnant women during ANC visits (routine distribution)

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9. Long-lasting insecticide-treated malaria bed nets purchased and/or distributed (number) (core indicator)

Subcomponent 1.2: Community-based nutrition services for pregnant women and young children

Improved utilization of nutrition services by pregnant women and children under five

10. Percentage of children under 2 years of age who attended the GMP session at least once during the previous month in the regions (Centrale & Plateaux) supported by the project; and 11. Percentage of household with children under age of two which was visited by CHW to support infant and young child nutrition (IYCN) practices.

Component 2: Strengthen the M&E system, the Government’s capacity to monitor its MCH programs, and project coordination and implementation support Sub-component 2.1: Strengthen the HMIS system and the Government’s capacity to monitor its MCH programs Effective supervision of service providers (health facilities and ASC) and Functional HMIS

12. Health Facility Master list developed and updated as planned

Component 2.2: Project management including coordination and implementation support

Effective supervision of project implementation

13. Percentage of health facilities submitting standardized HMIS monthly reports within one month of the reporting month; 14. Percentage of districts where receipt of at least 25% of HMIS reports was verified; and 15. Direct project beneficiaries (number) of which women (percentage). (%).

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Arrangements for Results Monitoring

Project Development Objectives

PDO Statement

The project development objective is to increase utilization of selected maternal and child health services for pregnant women and children.

Table 1.2: Project Development Objective Indicators

Cumulative Target Values

Data Source/

Responsibility for Data Collection

Definition

Indicator Name Core Unit of Measure Baseline YR1 2014

YR2 2015

YR3 2016

YR4 2017

End Target (Year 2018)

Frequency Methodology

1.Proportion of pregnant women who slept under a LLIN the previous night

Percentage 46.3% (MICS 2010)

50% 55% 60% 70% 75%

Every 3 years

MICS/MIS/DHS/HFS

MOH/PIU/PNLP

Numerator: Number of pregnant women who slept under a LLIN the previous night Denominator: Number of pregnant women.

2.Proportion of women who received IPT during ANC visits during their last pregnancy

Percentage 50.5%

MICS 2010,

51%

52.5%

53.5%

55%

56%

Annually

HMIS/Program reports/

MICS/DHS/HFS

MOH/PIU/PNLP

Numerator: Number of women who received 2 or more doses of a recommended antimalarial drug treatment during ANC visits to prevent malaria during their last pregnancy that led to a live birth within the last two years Denominator: Total number of women surveyed who delivered a baby in the

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last 2 years.

3. Proportion of suspected malaria cases tested by Community Health Worker) using a RDT

Percentage 0% 15% 28% 32% 46% 60%

Annually

HMIS/Progra

m reports MOH/PIU/PNLP

Numerator: Number of Suspected malaria cases tested by community health worker using a rapid diagnostic test (RDT) Denominator: Number of Suspected malaria cases presented to the community health worker.

4. Proportion of infants 0-5 months (less than 180 days) of age who were exclusively breastfed (Plateaux and Centrale regions)

Percentage

Plateaux: 50,8% Centrale: 65,2%

53% 67 % .

55% 70%

58% 73%

61% 75%

63% 77%

Every 3 years MICS MOH/PIU/PNLP

Numerator: Number of infants 0-5 months (less than 180 days) of age who were exclusively breastfed Denominator: Number of infants 0-5 months (less than 180 days).

5. Percentage of pregnant women attending ANC who received 90 IFA tablets during their last pregnancy in the project supported regions (Centrale & Plateaux)

Percentage

NA* (Baseline data will be updated during the first year of the project

15% (From

the baseline )

+25%(From the

baseline )

+30 % (From

the baseline )

+ 45% (From the baseline )

Annually

HMIS/Program reports

MOH/PIU

Numerator: Number of Pregnant women who attended ANC during their last pregnancy and received 90 tablets of iron folate Denominator: Number of pregnant women attending the ANC visit during their last pregnancy.

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

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6. Number of pregnant women receiving antenatal care during a visit to a health care provider (core indicator)

X Number HMIS 211041 230581 254030 281388 312653

Annually

HMIS/Program reports

MOH/PIU

Numerator: Number of pregnant women who receive antenatal care during a visit to a health care provider.

7. Percentage of pregnant women who attend at least four antenatal care visit during the last pregnancy in two regions (Plateaux & Centrale)

Percentage

50.6%

51.4%

52%

54%

54%

56%

57%

59%

60%

62%

63%

65%

Annually

HMIS/Program reports

MOH/PIU

Numerator: Number of pregnant women with at least 4 ANC visits. Denominator: Total number of pregnant women.

8. Number of LLIN distributed to pregnant women during ANC visits (routine distribution of LLIN)

Number 0

42002

45757

210929

230477

521165

Annually

HMIS/Program reports

MOH/PIU/PNLP

Number of LLIN distributed to Pregnant women who attended ANC visits.

9. Long-lasting insecticide-treated malaria bed nets purchased and/or distributed (number) (core indicator)

X

Number 0

42002

45757

210929

230477

521165

Annually

HMIS/Program reports

MOH/PIU/PNLP

Number of LLIN purchased and/or distributed LLIN.

10. Percentage of children under 2 years of age who attend the GMP session at least once during the previous month in the regions (Centrale & Plateaux) supported by the project

Percentage

NA (Baseline data will be updated during the first year of the project

+ 7 % (From

the baseline )

+15% (From

the baseline

)

+25% (From

the baseline )

+30%

(From

the

baseline )

+45%(From the

baseline )

Annually

HMIS/Program reports

MOH/PIU/ Nutrition Program

Numerator: Number of children under age of two who attended the Growth Monitoring and Promotion (GMP) session during the previous month in Plateaux and Centrale Denominator: Number of children under age two in the Plateaux and Centrale regions.

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28 Submitted to the district health authorities from the health facilities. 29 The verification modalities of the HMIS report will be defined in the HMIS implementation manual.

11. Percentage of households with children under age two which was visited by CHW to support Infant and young child nutrition practices in the Centrale and Plateaux regions

Percentage 0% 10% 25% 40% 50% 60%

Annually

HMIS/Program reports

MOH/PIU/ Nutrition Program

Numerator: Number of household with children under age of two which was visited by CHW to support Infant and young child nutrition practices in the project supported regions Denominator: Number of household with children under age two in the Plateaux and Centrale regions.

12. Percentage of health facilities submitting standardized HMIS monthly reports within one month of the reporting month

Percentage 0%

10%

30%

45%

55%

70%

Annually

HMIS/Program reports

MOH/PIU/ DISER

Numerator: Number of health facilities submitting standardized HMIS monthly reports within one month of the reporting month Denominator: Number of health facilities involved in the routine data collection.

13. Percentage of districts where at least 25% of the received28 HMIS reports was verified29

Percentage 0% 5% 15% 25% 35% 50%

Annually

HMIS/Program reports

MOH/PIU/ DISER

Numerator: Number of health district where reception of at least 25% of the HMIS reports was verified Denominator: Number of health district enrolled in the HMIS.

14. Health Facility Master list developed and updated as planned

Master list non

available

Master list

developed

Master list

updated

HMIS/Program report MOH/PIU/

DISER

15. Direct project beneficiaries (number) of which women (percentage).

X Number (% of women)

0

1224340

(59%)

1259111

1294870

1331644

5109968 (59%)

Annually HMIS/Program report

MOH/PIU/ DISER

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Annex 2: Detailed Project Description

TOGO: Maternal and Child Health and Nutrition Services Support Project

PROJECT COMPONENTS 1. It is important to stress that the interventions proposed under this project are not stand-alone activities or programs in their own right. The project seeks to reinforce existing approaches to promote and ensure MCH. Distribution of LLINs to pregnant women, IPTp, malaria and nutritional counseling, and IFA supplementation are all part of the package of focused ANC that should be available to all pregnant women in Togo. It is hoped that when a complete ANC package is offered to women, the uptake will improve and more pregnant women will demand the services earlier in their pregnancies. Similarly, community diagnosis and treatment of malaria are integral parts of C-IMCI, and fever is the most common symptom seen by CHWs. If CHWs are able to adequately provide diagnosis and treatment for malaria fevers, it will enhance their ability to deliver other C-IMCI interventions, including health promotion and education to reduce malaria risk and improve nutrition. The M&E system strengthening component will help the GoT to monitor progress in maternal and child health improvements, among others.

COMPONENT 1: Improved utilization of malaria and nutrition services (US$10.0 million)

Subcomponent 1.1: Support for (i) malaria control in pregnancy through provision of LLINs and SPs as part of the basic package of ANC services; (ii) community-based diagnosis and treatment of malaria; and (iii) management, supervision and behavioral changes to ensure effective utilization (US$7.0 million)

2. This sub-component responds to national priorities and to both the general and specific objectives of the National Strategic Plan (NSP) for the Fight against Malaria (2011-2015). A recently completed gap analysis by the national malaria program (the PNLP) identified two priority areas for additional investment: (i) support for the delivery of key malaria control interventions to pregnant women, specifically the distribution of LLINs and the provision of IPTp in ANC; and (ii) scale up the biological confirmation of malaria with RDTs, for both children and adults at the community level. 3. This project will address malaria in pregnancy by contributing to the package of services delivered through ANC. Specifically, the project will support the provision of IPTp with sulfadoxine-pyrimethamine (SP) and free LLINs to pregnant women attending ANC and aims to fill the funding gap (in complement to financing from the GoT and the GFATM Round 9 Grants). IPTp and LLIN, together with IFA and nutritional counseling (see subcomponent 1.2 below) are part of the basic package of ANC services. 4. The project will also address the community-based diagnosis and treatment of malaria by providing an adequate supply of RDTs (approximately 2.8 million test kits) to CHWs for parasitological confirmation of malaria in febrile patients, prior to treatment with ACTs; and through the activities described further below, the project will promote the effective uptake of project services and ensure the referral of negative cases to health

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facilities for follow-up. Malaria diagnosis and treatment are core elements of C-IMCI, as suspected, malaria is the most common reason for consultation with a community health agent. Community-based diagnosis using RDTs will ensure that all persons who live more than five km from a health facility and seek care for malaria are treated with antimalarials only if the RDT result is positive. Treatment of confirmed uncomplicated malaria should ideally begin within 24 hours of symptom onset to prevent progression to life-threatening severe malaria. When the RDT result is negative, the potentially serious non-malarial febrile patient is to be referred to a higher level for adequate treatment30. The cost of commodities to be provided under subcomponent 1.1 is inclusive of commodity cost, shipment, warehousing, and distribution and provides partial funding for local planning, social mobilization, monitoring and evaluation and supervision, which will be supplemented by additional project resources.31 5. The distribution of LLIN to pregnant women and the provision of SP for IPTp are to be conducted as part of the focused ANC package for all women attending ANC countrywide. This will reduce the risk of acute malarial illness in pregnant women (all malaria infections in pregnant women are considered severe) and will contribute to reduce anemia and overall improve pregnancy outcomes and improvements in birth weight. 6. Management strengthening, supervision, and change messages through community stakeholders would be crucial for ensuring that bednets, RDTs and SP for pregnant women are appropriately distributed and adequately utilized. The GoT and project staff would be responsible for ensuring management strengthening and close supervision (including communication strategies, training, M&E, supervision and social mobilization); and community health workers and local NGOs could be involved in transmitting behavior change messages to promote the effective uptake of project services. 7. Other priority program areas in the fight against malaria, including facility-based management of suspected malaria fevers and the mass distribution of LLIN, are largely financed by the GFATM and the GoT.

Subcomponent 1.2: Community-based nutrition services for pregnant women and young children (under five) (US$3.0 million)

8. The activities under this subcomponent are fully aligned with the country’s 2010 National Nutrition Policy and the 2012 National Nutrition Strategic Plan; they are also complementary to those already carried out by other GoT partners in this area, especially UNICEF. They will support the expansion of the country’s community-based nutrition services to two central regions (Centrale and Plateaux) in the country, and any other target region selected by the government, through: (i) the reinforcement and implementation of community-based prevention of malnutrition; and (ii) provision of IFA supplements to pregnant women as part of their basic package of prenatal care. The two geographic areas for this intervention were selected based on two criteria: (i) complementarity with existing nutrition interventions, and (ii)

30 There is a current gap of US$2 million nationwide of ACT at community level which the project will only be able to address if the project budget is increased. 31 Annex 7 provides additional technical analysis on malaria, including treatment costs, cost effectiveness, resistance and efficiency.

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prevalence of chronic malnutrition. Currently, all nutrition activities supported by UNICEF are heavily focused on the two northern regions of Savanes and Kara which have a relatively high prevalence of stunting. The selected regions of the project’s interventions, Centrale and Plateaux, however, have the second and fourth highest prevalence of chronic malnutrition in Togo, respectively, and are currently not covered by any routine or preventive nutrition services. The Savanes and Kara regions have the first and third highest prevalence of chronic malnutrition. 9. Activities will focus on the prevention of chronic undernutrition during the 1,000 day window of opportunity (from conception until two years of age), a critical period beyond which impairments in growth and development can be irreversible. The main activities under this subcomponent include the following:

Activity 1: Preventive Package of Nutrition Services:

Monthly growth monitoring and counseling to promote breastfeeding, IYCN practices, management of childhood illnesses, and safe water, hygiene and sanitation. For children under two years of age, length, weight, and mid-upper arm circumference (MUAC) will be measured on a monthly basis. For children two to five years of age, only MUAC will be measured to screen for acute malnutrition;

The CHW and one member of the PIU support group will visit households with children under two years of age once per month to provide one-on-one breastfeeding support and IYCN counseling;

Referral of sick and severely acutely malnourished children to the health facility for treatment; and

Monthly feedback sessions with the health facility to review progress, discuss challenges and find potential solutions.

Activity 2: IFA Supplementation of Pregnant Women

All 12 districts in the Plateaux region are included in the calculation; the costs of training, supplies, motivation/compensation only include 50% of the total number of CHWs in each of the two regions; the percentage of the population that is expected to be pregnant is 3.26%. This figure was confirmed by the National Nutrition Service. New WHO guidelines show that, in malaria-endemic areas where malaria programs are in-place, iron supplements for pregnant women are recommended.

10. The component includes goods (IFA, scales) and services (community mobilization and training/retraining of CHW and volunteers). Stakeholders involved in the implementation would also include communities themselves and their volunteers, direct beneficiaries, local governments in project areas, the national nutrition program, health facility staff and health sector NGOs. 11. For malaria and nutrition activities, the stakeholders involved in the implementation would include communities and their volunteers, the direct beneficiaries, local governments in the project areas, the national malaria, maternal health, IMCI (and EPI) programs, the nutrition services, health facility staff, and health sector NGOs.

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12. The CHW will be the primary agent for community interventions to reduce the burden of malaria (biological diagnosis and treatment of malaria in the context of community IMCI) and combat malnutrition (exclusive breastfeeding, improvement of infant and young child feeding practices and growth monitoring). The CHW who will be contracted to implement the project activities will receive training, materials (drugs, diagnostics, scales and communication aids) and enhanced formative supervision under the project. Financial incentives will also be paid to full time CHWs contracted under this project in the Central and Plateau regions where a comprehensive package of services for malaria control and prevention of chronic malnutrition will be carried out at community levels. In line with the Government policy on community-based interventions, the CHW will be principally responsible for areas beyond five km from a standing health facility; for areas within five km of a health facility, health facility workers will be responsible for carrying out the activity. 13. The project’s proposed community-based approaches for delivering some of the project’s services would offer an opportunity for learning lessons with potentially wider relevance, particularly in the light of few African experiences of successful community approaches, in contrast to, say, Asia. 14. The GoT has recently shown interest in experimenting with demand-side financing and other incentives to improve quality, efficiency and general health system performance. This interest might provide another opportunity for the project to support the GoT to lay the foundation for performance-based financing (PBF) approaches through policy dialogue and analytical work so as to inform their future design and implementation of such schemes.

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Figure 2.1: UNICEF (1998) Conceptual framework for the causes of child undernutrition.

15. Component 1 of the project will address two major underlying causes of child undernutrition which are identified in the UNICEF (1998) framework. Subcomponent 1.1 will specifically address the “health” component in the underlying causes by reducing exposure to malaria infections for both pregnant mothers and young children under five (see Figure 2.1). Moreover, subcomponent 1.2 will address the “care” dimension in the underlying causes by promoting optimal feeding and care practices, such as breastfeeding, appropriate complementary feeding, and hygiene and health seeking behaviors to promote good nutrition. 16. By addressing these two underlying causes (health and care), Component 1 will also indirectly influence the immediate causes of maternal and child undernutrition, namely inadequate dietary intake and diseases (see Figure 2.2).

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Figure 2.2: Immediate causes of child undernutrition. __________________________________________________________________________

17. By addressing two underlying causes of child and maternal undernutrition together, Component 1 also aims at creating synergies which will help in breaking the infection-malnutrition cycle (see Figure 2.3).

Figure 2.3: The infection-malnutrition cycle

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COMPONENT 2: Strengthening Health Monitoring and Evaluation Systems; Project Management (US$4.0 million)

Subcomponent 2.1: Strengthening the health monitoring and evaluation system, particularly the HMIS, including the Government’s capacity to monitor its MCH programs (US$2.6 million)

Status of HMIS System in Togo 18. In April 2003, the MoH carried out an evaluation of the existing HMIS in Togo using the well-known WHO tool (the Health Metrics Network Assessment tool). The outcomes of the assessment were presented during a workshop organized by the MoH and the World Bank as part of the proposed project preparation. The findings of the evaluation and the two days’ workshop confirmed the previous Bank assessment of the HMIS included the Country Status Report. The allocated resources (human and financial) to the HMIS system are very limited, the

HMIS department is lacking basic ICT equipment and furniture; the staff involved in the HMIS are not very well trained and are lacking the required competencies.

The conceptual framework of the HMIS system defining the data management process

(collection, analysis and use of data) is not well known and respected. In addition, the system is very fragmented among the vertical health programs (EPI, Malaria, Nutrition, TB, HIV/AIDS, etc.) which are mostly supported by different development partners. An effective coordination between these different parties involved in the HMIS system is missing.

The presence of a multitude of data collection tools with different transmission channels: every vertical program has introduced its own data collection tools with specific transmission channel, and this creates an additional workload for the service providers. There is no defined mechanism of data validation and quality control process.

Limited capacity to analyze and use the produced data at different levels of the health

system. Data are analyzed mostly by vertical program managers (since each program is collecting its own data), therefore the HMIS entities at the different levels of health system (district, regional and central) are not regularly involved in the data analysis. The data retro information process does not exist.

Proposed support to the HMIS 19. The draft HMIS strategic plan has identified the following strategic axes to reinforce the HMIS system: (i) reinforcement of institutional framework; (ii) improvement of data production and management capacities including data quality control and analysis; and (iii) dissemination and utilization of information for evidence-based policy and appropriate resource allocation. The project’s scope of the HMIS subcomponent is aligned with the strategic framework and will focus on: (i) reinforcement of routine HIS; and (ii) support to the implementation of periodic health facility survey to gather additional data.

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20. Strengthening the routine Health Information System. Currently, as described above, data collection and management process are under the control of vertical programs and respective development partners. Without putting an immediate end to this existing process, the MoH will proceed toward the establishment of an integrated HIS.

21. Therefore, the project will support strengthening the system’s institutional framework of the system which will define the roles and responsibilities of different stakeholders/implementers of the HMIS system, thereby reinforcing the newly established DISER and setting up a functional coordination body chaired by the MoH, involving all interested parties in the development of HMIS system. The consulting firm to be recruited by the project will provide the required technical support to MoH to revise and strengthen the institutional framework. 22. A set of minimum core indicators with appropriate data collection and reporting tools will be developed, pre-tested and implemented. A standardized data transmission channel will be adopted and implemented. 23. The quality of the collected data will be improved and, for this purpose, a data verification and validation mechanism, including timeliness, completeness and accuracy of data, will be developed and implemented. The district health team will be given special attention (improve capacity) to perform this task. 24. The data storage, analysis and dissemination will be improved through support to MoH’s ongoing initiative to introduce the DHIS2 with support of the Oslo University. DHIS2 is currently being piloted in five districts. The project will help evaluate the ongoing pilot and scale up of DHIS2 as a core element of HMIS strengthening process. DHIS2 is web-based, and GIS features tool implementation which will require availability of comprehensive list of service providers (Master Health Facility List) with their essential information (type of health facility, location with geographical coordinates, available staff, provided services, etc.). Therefore, the project will support the establishment and updating of the Master Health Facility List. Implementation modalities of the HMIS and timeframe 25. Strengthening of the routine HIS will be carried out based on the following steps: 26. Preparatory phase (3-4 months): During this phase, and with support of a M&E consulting firm (to be recruited), the MoH will (i) review and finalize the conceptual framework (identification of major participants to the system and definition of their respective roles and responsibilities, identification and finalization of essential set of indicators; (ii) update, finalize and pre-test the data collection and reporting tools with appropriate guidelines and training materials; (iii) develop a data validation methodology and (iv) adapt DHIS2 in order to include data reporting tools. The implementation of this phase will be initiated as soon as the Project Preparation Funds are available.

27. Pilot phase :(8-9 months): Implementation of the revised routine HIS will be piloted in two regions of the country (Lomé and Maritime) which comprise 12 health districts out of 40

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and 25% of primary health care facilities. The pilot phase will be evaluated with the objectives of defining appropriateness of selected indicators, data collection and reporting tools and data transmission channels, utilization of DHIS2, provision of recommendations for the improvement of the system, development HIS scale up plan. 28. Scale -up phase (24 months): During this phase, the routine HIS system will be rolled out in the country (six regions, 40 districts, and all public and confessional primary health care facilities). A the end of this phase, an evaluation of the system will be carried with the purpose of assessing the progress, identifying the potential bottlenecks and with appropriate measures to be implemented within the last year of the project. 29. Support to periodic Health facility Survey: It is obvious that the routine HIS will not provide all essential information to monitor the progress of the health system in general, and the current project in particular. The MoH recently carried out a health facility survey and, within it, two surveys (SARA and SDI) were implemented with the respective support of WHO and the World Bank. Although findings of these surveys are not yet finalized, the MoH has recognized the importance of generated information to effectively monitor the health system and has decided to undertake them on a regular basis. 30. The project will support the implementation of health facility survey coupled with household survey in the catchment areas of selected health facilities. The aim of this survey is to gather reliable information on the availability, quality and utilization of basic package of health services. This survey will also generate data to inform few indicators of the project result framework. It is planned to undertake two or three surveys within the project life with a baseline survey in FY15, and two other surveys in FY17 and FY19. The project’s Mid-Term Review would also be an important tool to help with a successful implementation.

Subcomponent 2.2: Project coordination and implementation support (US$1.4 million)

31. The proposed project will also support the MoH to manage and coordinate the implementation of project activities. This will include: (i) coordination and planning; (ii) financial management and audit; (iii) procurement and supply chain management; and (iv) training and supervision. The subcomponent will also support costs related to external experts that will support the functioning of the PIU, including a Procurement Specialist, an FM Specialist and M&E Specialist32 as well as operating costs. It will also provide relevant additional support to technical programs involved in project implementation.

32 While external experts (FM, procurement and M&E) will be financed by the project, the Project Coordinator and MoH staff delegated to work as part of the PIU will be funded by the Government.

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Annex 3: Implementation Arrangements

TOGO: Maternal and Child Health and Nutrition Services Support Project

Project administration mechanisms 1. Graphically, the proposed institutional arrangement of the project is as follows. Figure 3.1: Proposed institutional arrangements The roles and responsibilities of each actor are summarized below.

Regional/District Health authorities

Health facilities

Community Health

Workers

Supervise Technical support

Support with goods and services

Ministry of Health General Directorate

Project Implementation Unit Project Coordinator,

FM/Procurement/M&E Specialists, National homologues

Project Monitoring Group

MoH Programs and Services

(Malaria Program, Nutrition Services, DISER,

DAC, DSF)

Beneficiaries (households and communities)

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Table 3.1: Roles and responsibilities of actors involved in the project Project Monitoring Group33

The Project Monitoring Group will oversee the implementation of the project. They will meet every quarter and will be responsible for project oversight, including, among others, provision of overall project guidance, approval of annual work plans and budgets, and facilitate coordination of project activities.

MoH (General Directorate) Within the MoH, the General Directorate will be the implementing agency for the project. Core members of the PIU will be selected within the MoH who will receive technical support from external experts in the areas of FM, procurement and M&E.

Various Programs and Divisions, including the PNLP, Nutrition Services and the Divisions for Community Health (DSC), Information Statistics, Studies and Research (DISER), Communal Affaires (DAC) and Family Health (DSF)

They will provide technical support to the MoH General Directorate in charge of implementing the project when required and will also be part of the Project Monitoring Group.

Staff in regional health administration

They will provide supervisory and coordination role at decentralized levels. Through Component 2, they will benefit from training and new IT equipment, and will be responsible for consolidating/verifying data at the regional level.

Staff in district health administration

They will provide supervisory and coordination role, especially in the management of health facility workers. Through Component 2, they will benefit from training and new IT equipment, and will be responsible for consolidating/verifying data at the district level.

Health facility workers They will deliver services to be provided within the context of ANC services, and also supervise the work of CHWs

Community health workers (CHW)

Through Component 1 (malaria and nutrition), they will receive training, supervision as well as goods (LLIN, RDTs, IFA) so to implement community-based malaria and nutrition activities. The CHWs to be supported under the project will operate in areas that are beyond five km from a standing health facility.

Community level NGOs Under Subcomponent 1.2 (nutrition), based on the

33 As noted in the main text, under implementation arrangements, the Project Monitoring Group and the Project Implementation Unit have already been created by Ministerial Orders.

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outcome of the assessment planned before project start, they could be contracted by the MoH to carry out activities related to community mobilization and Information, Education and Communication. In addition, they will support the health facilities in monitoring and supervising the CHWs.

Household & communities They will benefit from improved access to prevention and treatment of malaria and malnutrition; and provide feedback through periodic surveys to improve programs

2. A PIU has been established within the MoH under the General Directorate34. The PIU will assume, among others, fiduciary responsibilities, overall coordination and planning, internal auditing and M&E. The MoH has appointed a national Project Coordinator who will work full time on the project and will lead this team. Other members of the team to be monitored by the MoH will include those responsible for FM, procurement, M&E and communication, and administrative assistant(s), accountant and secretary. These staff will be nominated by the MoH and their costs will be covered by the Government. In order to reinforce the capacity of the MoH staff, external experts for FM, procurement and M&E will also be recruited prior to project effectiveness. 3. To ensure long-term capacity building, each of these external experts will be responsible for coaching the MoH Staff (homologue) responsible for FM, procurement and M&E. The objective is to ensure that, before the end of the project, the national capacity has been strengthened and is able to take over project activities without any external support. This arrangement has been already tested with the World Bank-financed education project in Togo and has so far yielded satisfactory results. 4. To ensure sufficient dedication and adequate learning, the proposed arrangement will have the following features: Each national MoH civil servant who will be nominated as a secondee (homologue

nationale) responsible for FM, procurement, M&E and communications will be selected by the MoH. The list of selected candidates will have to be approved by the Bank.

Each homologue will receive some logistical support. In particular, communication and transportation costs (as long as they are incurred due to their involvement in the Project) will be covered by the project.

Each secondee will have a detailed and customized knowledge transfer plan. The coordinator and the project’s external experts will be accountable for the implementation of these plans.

5. The composition of PIU staff (external experts and MoH staff, their recruitment method and timeline are described below).

34 Arrêté No. 131/2013/MS/CAB/DGS Portant création, attributions et composition de la Cellule de gestion du Projet du PASMIN financé par la Banque mondiale

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Table 3.2: Composition of PIU staff and recruitment method Staff Recruitment Timeline

Project Coordinator (MoH)

Appointed by the Minister of Health. MoH to cover the costs.

The PNLP Coordinator was already appointed as Project Coordinator and currently serves as a Focal point for project preparation.

Procurement Specialist (external)

International competitive selection by a recruiting firm.

The recruitment process should be completed before project start. This is an effectiveness condition.

Financial management Specialist (external)

International competitive selection by a recruiting firm.

The recruitment process should be completed before project start. This is an effectiveness condition.

M&E Specialist (external)

International competitive selection by a recruiting firm.

The recruitment process should be completed before project start. This is an effectiveness condition..

Procurement staff (MoH) Selected and funded by the MoH . He/she will be the ‘national homologue’ and will work closely with the international expert, based on a competency transfer plan.

To be nominated before project start. This is an effectiveness condition.

Financial management staff (MoH)

Selected and funded by the MoH. He/she will be the ‘national homologue’ and will work closely with the international expert, based on a competency transfer plan.

To be nominated before project start. This is an effectiveness condition.

M&E Staff (MoH) Selected by have tended to be project specific and the relevant MoH services and will work part time on the project.

To be nominated three months after effectiveness.

Communication staff (MoH)

Selected by the relevant MoH services and will work part time on the project.

To be nominated three months after effectiveness.

6. For the procurement of drugs and medical supplies, it is envisaged to use the Central Drug Procurement Unit (Centrale d’Achats de Médicaments Essentiels et Génériques (CAMEG)) if the procurement capacity assessment determines that their procurement procedures are satisfactory (see Annex 4 under Procurement). If CAMEG is not appropriate or needs further

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reinforcement35, other procurement arrangements (e.g. procurement at least initially through appropriate UN agencies) will be considered. 7. Integrated ANC services will be provided at the facility level by trained health personnel. Training, formative supervision and quality assurance for service provision will be the responsibility of the District Health Management team. 8. In Togo, there are several experiences with incentives payment for CHWs however these a coherent system for managing and providing financial incentives to community workers at the national level is not currently in place. Payment of incentives is also encouraged in their National Strategy for Community-based interventions36 and donors such as UNICEF and GFATM, albeit slight differences in the approach and difference in the amount paid, have been incentivizing their CHWs to implement their activities that are heavily reliant on CHWs. Financial Management and Disbursements 9. The PIU will handle the overall responsibility of Financial Management (FM) aspects of the project including: (i) managing the Designated Account, (ii) preparing Withdrawal Applications and reporting to be submitted to the World Bank. Funds Flow and Disbursement arrangements

Designated Account

10. One Designated Account (DA) will be opened at a commercial bank acceptable to IDA. Its ceiling will be set to CFAF 700 million estimated to cover four months of eligible project expenditures during the highest disbursement period. The Project Coordinator and the FM specialist will be the signatories of the DA. The account is set up to fund eligible expenditures based on the approved annual activity plans. Five (5) regional advances accounts will be opened to finance activities to be executed at the decentralized levels (regional and health districts levels). Disbursements from these sub-accounts will comply with specific procedures to be included in the project manual. Disbursement methods and processes 11. Disbursements under the project would be transaction-based. After project effectiveness and upon receiving a Withdrawal Application, IDA will disburse an initial advance (up to the ceiling of the DA) to the designated account. Subsequent advances to the DA will be made

35 Note that the new French AFD project under preparation envisages reinforcing the capacities of the CAMEG, so this may require close coordination with AFD and CAMEG to assess improvements in the latter’s capacities in the course of time if the initial assessments are not favorable. 36 The national strategy for community-based interventions recommends an incentive payment for full time CHWs (US$60/month) and part-time (US$30/month). In discussions with Government officials, the team was advised that, in reality, this amount is not respected due to budget constraints, with the State paying US$10/year, and key donors, such as UNICEF and GFATM, paying approximately US$10/month. Additional incentives may be needed for “CHW supervisors” and members of the Groupe de Soutien à l’Allaitement Maternel.

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against withdrawal applications with supporting documentation (Statements of Expenditures (SOE) or records) reporting eligible expenditures paid from the DA. In addition to making advances to the Designated Account, other disbursement methods (such as reimbursement, direct payment and special commitment) will be available for use under the project. The minimum value of applications for these methods is 20% of the DA ceiling. Further instructions on disbursement and details on the submission of the Withdrawal Applications will be outlined in the disbursement letter. 12. Table 3.3 sets out the expenditure categories to be financed out of grant proceeds. Grant proceeds will be disbursed in accordance with the project’s categories of expenditures as shown below. The percentage of financing is 100% inclusive of taxes in line with the current Country Financing Parameters approved for the Republic for the Togo.

Table 3.3: Disbursement table

Category Amount of the Grant

Allocated (expressed in US$)

Percentage of Expenditures to be

Financed (inclusive of Taxes)

Goods, works, non-consulting services, consultants’ services, Training and Operating Costs for the Project

13 ,450,000 100%

Reimbursement of PPA 550,000 100%

Total Amount 14,000,000

Flow of funds

13. Funds will flow from the Grant Account through the DA. The Direction du Financement, du Contrôle de l’Exécution et du Plan (DFCEP) and the Public Treasury would be the assigned representatives of the Recipient for the mobilization of IDA funds. Withdrawal Applications will be prepared by the Project FM Specialist, signed by a designated signatory or signatories (the signature authorization letter is signed by the Minister of Finance), and sent to the Bank for processing. The signatories will have the option to submit electronic applications using the “eDisbursement” module available on the Bank’s Client Connection website. Reporting and Auditing arrangements 14. Quarterly Interim Un-audited Financial Reports (IFRs) will be prepared by the FM Specialist. IFRs including specific information on IDA financing will be submitted to the Bank within 45 days following the end of each quarter. 15. The MoH PIU will produce Annual Financial Statements for the Project which will comply with the local accounting standards (SYSCOHADA).

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Audit arrangements Internal controls and audit 16. The project internal control procedures will be described in the project procedure manual. The internal audit function will be assumed by the General Inspectorate of Finance (IGF) which is responsible for the internal audit of the use of public fund at the national level. An agreement will be concluded with the IGF until project closure to include the project audit in the IGF annual work program. This will contribute to reinforce the project governance and to mitigate fraud and corruption risks inherent to the public sector in Togo. External audit 17. The Supreme Audit Institution (Cour des Comptes, or SAI) which is supposed to audit all public funds has a limited capacity in terms of staffing and experience of auditing project financial statements. In view of this, it was agreed that an external independent and qualified private sector auditor will be recruited to carry out the audit of the project’s financial statements under the supervision of the supreme audit institution. Therefore, annual audits will be conducted based on Terms of References (TOR) agreed with the SAI and that are satisfactory to the Bank. 18. The Auditor will express an opinion on the Annual Financial Statements and perform his audit in compliance with International Standards on Auditing (ISAs). He will be required to prepare a Management Letter detailing his observations and comments, providing recommendations for improvements in the accounting system and the internal control environment. The audit report on the annual project financial statements and activities of the Designated Accounts will be submitted to IDA within six months after the end of each project fiscal year. Procurement 19. Capacity Assessment, Risk and Mitigation Measures: A procurement capacity assessment of the MoH and Central Drug Procurement Unit (Centrale d’Achats de Médicaments Essentiels et Génériques (CAMEG)) was conducted during project preparation, from February 26 to March 7, 2013. The procurement committees required by the national procurement code are formally established under the MoH. The CAMEG, with staff having relative procurement experience, but not qualified with the Bank's procurement procedures, is also partially available. The potential risks identified are the lack of experience with Bank’s project implementation procedures and the absence of a procurement manual for the MoH. Therefore, the mitigation measures agreed upon are to: (i) recruit an external Procurement Specialist; (ii) nominate a project Procurement Officer within the Ministry’s civil servant; (iii) use the external Procurement Specialist to assist the MoH for complex/specialized procurement; (iv) organize procurement training for MoH staff involved in the project procurement process; and (v) prepare a project procurement manual as part of project Administrative and Financial Procedures manual (procedural manual). The Bank’s approval of an acceptable project procedural manual will be one of the effectiveness conditions for the project.

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20. The PIU will oversee and manage the project, and as such, it will ensure that procurement activities are proceeding in a timely manner and according to project objectives. All project procurement prior review documents should be submitted to IDA through the PIU in MoH. The project procurement activities will be carried out by the PIU, who could delegate drugs and medical supplies procurement activities to Togo’s CAMEG, or to an appropriate UN agency, as needed. 21. Through the project implementation team, CAMEG and the MoH will work together to ensure adequate delivery schedules (frequencies and quantities) by considering the existing storages capacities. CAMEG is experienced in the procurement of drugs and medical supplies and is adequately staffed. 22. Taking into consideration the MoH procurement experience with GFATM projects and the organization of internal and external procurement controls, the overall project procurement risk has been rated as Moderate. 23. Procurement Documents: Procurement will be carried out using the Bank’s Standard Bidding Documents or Standard Request for Proposal (RFP) for all International Competition Bidding (ICB) for goods and for the selection of consultants, respectively. For National Competitive Bidding (NCB), the Borrower should submit a sample form of bidding documents to the Bank for prior review and will continue to use this type of document throughout the project; once this has been agreed upon, it could become the national Standard Bidding Documents. The Sample Form of Evaluation Reports published by the Bank will be used. 24. CAMEG has its own standard bidding documents and procedures which are under review by the Bank Procurement Specialist in the Togo Country office. These documents may be used for the proposed project provided that the following modifications are introduced: (i) directives to bidders should include specific mention of the clauses related to corruption; (ii) bid evaluation results should be published; and (iii) preferential margins clauses should be revised so as to be applied only when account of the origin of goods is being taken. 25. Frequency of Procurement Reviews and Supervision: The Bank’s prior and post reviews will be carried out on the basis of thresholds indicated in the Table 3.3. The Bank will conduct bi-annual supervision missions and annual Post Procurement Reviews (PPR); frequency of post reviews will be at least one out of five contracts. The Bank could also conduct an Independent Procurement Review (IPR) at any time until two years after the closing date of the project.

Table 3.4: Procurement and Selection Review Thresholds

Procurement/selection methods

Prior review threshold

(US$)

Comments

1. Works and Goods ICB

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Procurement/selection methods

Prior review threshold

(US$)

Comments

• Works • Goods

≥ 5,000,000 ≥ 500,000

Method can be applied for any amount, but is mandatory for contracts above the prior review thresholds

LCB ≥ 300,000 Review of all contracts NCB N/A Review of the first two contracts independently of

amount. The method is applicable only for contracts less than US$5,000,000 for works and less than US$500,000 for goods

Shopping N/A Review of the first two contracts, independently of amount. Method applicable for contracts less than US$100,000 for works and goods

Procurement from United Nations Agencies

All amounts The standard form of Agreement, between a Borrower and a UN agency, approved by the Bank shall be used

Direct Contracting All amounts Review of all contracts 2. Consulting Services

QCBS ≥ 300,000 Review of the first two contracts independently of amount

LCS ≥ 200,000 Review of the first two contracts independently of amount

Selection under a Fixed Budget (FBS)

≥ 200,000 Review of the first two contracts independently of amount

CQS (for contracts ≤$US200,000) ≥ 100,000

Review of the first two contracts independently of amount. Method could be applicable for contracts less than US$200,000

Individual Consultants (IC) ≥ 100,000 Review of the first two contracts and other contracts chosen on a case-by-case basis, independently of amount.

Single Source Selection (SSS) All amounts Review of all contracts. 3. Training and Workshops

Training and workshops ≥ 10,000 On the basis of a detailed and approved annual plan (with indication of venue, number of participants, duration, detailed budget, etc.)

26. All training, terms of reference of contracts estimated for over US$10,000, and all amendments of contracts raising the initial contract value by more than 15% of the original amount or above the prior review thresholds will be subject to IDA prior review. All contracts not submitted for prior review will be submitted to IDA for post review in accordance with the provisions of paragraph 4 of Annex 1 of the Bank’s Consultant Selection Guidelines and Bank’s procurement Guidelines 27. Procurement Plan: All procurement activities will be carried out in accordance with the approved original or updated procurement plans. The procurement plans will be updated at least annually or as required to reflect the actual project implementation needs and capacity

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improvements. All procurement plans should be published at the national level and on the Bank website according to the Guidelines. The Government has prepared a procurement plan covering the first 18 months of the project. Tables 3.4 (a), (b) and (c) below represent a summary of this procurement plan.

Table 3.4 ( a) Summary of goods and non-consulting services

Goods and Non consulting Services

Ref Contract (Description) Estimated Cost US$

Procurement Method

Pre- qualific

ation (yes/no)

Domestic Preference (yes/no)

Review by Bank

(Prior/Post)

1 Computer hardware and installation

231,700 NCB No No Prior

2 Vehicles 680,400 Shopping No No Prior

3 Office equipment 9,900 Shopping No Yes Prior

4 Office furnitures 4,639 Shopping No Yes Prior

5 Long lasting insecticide nets

578,000 ICB Yes No Prior

6 Sulfadoximepyrimethamine

108,000 NCB Yes No Prior

7 Rapid diagnostic tests 263,000 NCB Yes No Prior

8 Scales 1,035,000 ICB No No Prior

9 Production of data collection tools

125,000 Shopping No No Prior

10 IFA tablets 294,000 NCB Yes No Prior

11 Hemocues and Micrucuvettes for hemocues

217,000 NCB Yes No Prior

12 Motorbikes for supervision 5,600 Shopping No No Prior

13 Minor rehabilitation of office 10,000

Shopping No Yes Prior

14 Internet connection and installation 11,300

Shopping No yes Prior

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Table 3.4 (b) Summary of Consulting Assignments

Ref Description of Assignment

Estimated Selection Review by Bank

Cost US$ Method (Prior / Post)

1 Firm for personnel recruitment 8,000 CQS Prior

2 Procurement Specialist 108,000 IC Prior

3 FM Specialist 58,000 IC Prior

4 M&E Specialist 54,000 IC Prior

5 Expert for DRS/DPS fiduciary capacity assessment 8,200 IC Prior

6 Financial audit 20,000 CQS Prior

7 TA to support the M&E component (development of M&E Plan and relevant documents, development of data collection tools)

65,000 QCBS Prior

Table 3.4 (c) Summary of Capacity building activities

Ref Activity Description

Estimated Review by Bank Estimated

Duration Cost US$ (Prior /

Post)

1 Project launching workshop 8,000 Prior 1 day

2 Workshop for elaboration/validation of procedural manual

14,600 Prior 1 day

3 Workshop for elaboration of monitoring manual 14,600 Prior 1 day

4 Workshop for project implementation 2,000 Prior 1 day

5 Training of 50 accountants 30,000 Prior 1 day

6 Training of DPS/DRS on M&E 60,000 Prior 4 days

7 Training of 300 CHWs and supervisors 150,000 Prior 5 days

8 Training of PHU staff on integrated package of services

500,000 Prior 5 days

9 Training of data collectors: development of training materials, training of the trainers, initiate the training of data collectors

30,000 Prior 4 days

28. Procurement Filing. Procurement documents must be maintained in the project files and archived in a safe place for at least two years after the closing date of the project. The project Procurement Specialist will be responsible for filing procurement documents. Environmental and Social (including safeguards)

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29. The project will support the Government's program and thus cover the whole country. The project will support both central level (capacity strengthening) and community level activities. For malaria-control activities, the project will finance the purchase and distribution of insecticide-treated bed nets, rapid diagnostic test kits and drugs. Activities related to nutrition will include nutritional supplements as well as medical test kits. The project will also finance computer and other equipment. The project will not finance any construction or any renovation. The issue of medical waste disposal need to be addressed as the rapid diagnostic test kits for malaria uses blood specimens. The bednets have the insecticide incorporated into or affixed to the fiber, so there will be no management of insecticides as there would be in a spraying intervention. 30. Environmental policy OP/BP 4.01 - Environmental Assessment will be triggered. The Ministry has already developed a MWMP with support of the WHO and other partners which has been judged acceptable to the Bank. However, as this Plan spannned the 2010-2014 period, it did not cover the implementation period of this project. To make the MWMP a relevant safeguards instrument for this project, the MWMP was updated to cover the entire project life and was judged acceptable to the Bank. The revised MWMP has been published in country through the MoH website and in Infoshop.

Monitoring & Evaluation of the Project

31. The main source of data for project indicators are routine HIS which, as mentioned earlier, is fragmented among vertical programs. The project is investing in developing an integrated harmonized system which is expected to be fully operational by the end of the third year of project implementation. Meanwhile, the existing system will be maintained and used to generate data related to project indicators. The two programs (malaria and nutrition programs) which are supported by the project have established a well-functioning data management system that is producing the required data. Additional specific tools will be developed to monitor the implementation of nutrition activities at the household level. 32. Health facilities will collect the reports from the CHWs, along with their respective reports, and will transmit them to DISER of district health team after internal verification. DISER will proceed to the verification of the report using a data verification method to be developed and transmit the compiled report of the district to the Regional Health Bureau. The Regional Health Bureau will verify and compile the district data into regional monthly report and will forward to the PIU.

33. The PIU will produce and share with the World Bank a quarterly implementation progress report which will include the updated result framework. The detailed contents of the quarterly implementation progress report will be described in the M&E section of the project implementation manual. The national HMIS system is fragmented among different vertical programs (Malaria, Nutrition, EPI, etc.) which have developed and introduced their data collection tools with specific transmission channel. Although the project is aiming to support the development of a comprehensive M&E system for the entire health sector, for the purpose of the project monitoring, the data will be collected using the existing tools. Additional specific tools will be developed to monitor the implementation of nutrition activities at the household level.

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Feedback/dissemination of the information: The M&E unit of the district health team will

provide written feedback to the respective health facilities on monthly basis. At the national level, the M&E staff of the PIU will produce quarterly progress reports which include the results framework and share it widely after approval by the MOH and the World Bank with implementers and other stakeholders. In addition, an annual review meeting will be organized to share progress and identify potential bottlenecks and propose appropriate measures.

Role of Partners 34. The interventions proposed under this project are not stand-alone activities or programs in their own right. The project seeks to reinforce existing approaches to promote and ensure maternal and child health. The project will support the current efforts of the Government and its partners, principally the GFATM, UNICEF and the AFD, to improve access to proven, cost-effective malaria control and nutritional support interventions through routine delivery of maternal and child health services at both facility and community levels. 35. Since 2004, malaria control in Togo has been supported by external financing from the GFATM. Togo has benefited from a total of five malaria grants. The principal recipient of the first three grants (total amount committed US$24.4 million) was UNDP37. The second grant is being implemented by the MoH. Phase one has ended with a performance rating of inadequate. Phase two is currently under negotiation. Of a total commitment of US$17 million, slightly more than 62% has been disbursed. These grants focus on the procurement and distribution of nets, training community leaders and health workers on the prevention and treatment of malaria, and behavior change communication activities – including provision of and training in the use of mobile audiovisual projection kits. The entire population of Togo will benefit from the program, which targets population groups most at risk from malaria: pregnant women and children under five. 36. IDA financing will fill gaps in the National Malaria Control Plan by financing activities that are inadequately covered by financing from the GoT, the GFATM and other development partners, such as UNICEF. Based on projected disbursements from the GFATM, the gaps will be greatest after 2015. However, given the current status of the MOH implemented GFATM grant (in negotiation following inadequate performance), larger amounts of IDA financing may be needed prior to end 2015. 37. UNICEF is currently implementing a community-based project to support improvement of nutritional status of pregnant women and children under five. Financed by the European Union, this 1.7 million Euro project reaches out to 240 villages and 112 health centers in the

37 The first two grants were closed after full disbursement, and the third grant is in the closure process with more than 92% of funds disbursed. At present, there are two sister grants in progress (technically, this is one grant with two principal recipients). One is being implemented by Plan Togo and has entered phase two implementation with a performance rating of adequate. US$19 320,007 out of US$24,433,100 committed have been disbursed to date. The grant will close on December 31, 2015.

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northern regions of Kara and Savanes38 In addition, UNICEF is also partnering with the World Bank for the implementation of the Social Protection Project which provides conditional cash transfer for improving nutrition outcomes at community levels. Their contribution to beneficiary identification, support to the Government in designing, implementing and supervising the training activities on nutrition, health and hygiene have provided useful lessons to the design of this project. While UNICEF is not involved in the two regions targeted under this project for nutrition-related activities, the project will draw on experiences of the successful WB-UNICEF partnership.

38 The project started in July 2011 and expects to close in January 2014; UNICEF is currently seeking additional funding sources to continue the activities.

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Annex 4: Operational Risk Assessment Framework (ORAF)

Togo: Maternal and Child Health Support Project (P143843)

Stage: Approval stage .

Risks .

Project Stakeholder Risks

Stakeholder Risk Rating Moderate

Risk Description: Prioritizing interventions may create some frustration among certain parties as the sector as a whole is underfunded, and there is a high demand in many areas. Coordination difficulties among the Government (both at the central and decentralized levels), partners and communities as it will involve a large range of entities and could potentially result in lack of clarity in roles and responsibilities, resulting in lack of motivation. Difficulty in understanding how a World Bank project operates, given that this is a new health operation by the World Bank after over 15 years of absence.

Risk Management:

All relevant Government strategies/operational documents were reviewed to ensure consistency with key priorities, both at the sector and program levels. The letter submitted by the Government requested Bank support in the area of malaria control and in subsequent consultations with them, they also identified nutrition and health systems strengthening (focusing on strengthening the M&E system) as urgent priorities, whose areas are entirely in line with the proposed interventions.

Resp: Bank Status: In Progress

Stage: Preparation

Recurrent:

Due Date:

Dec. 31, 2013

Frequency:

Risk Management:

The design and preparation of the project has been and will continue to be carried out in a consultative and participatory manner, involving not only the government, but also key development partners and civil societies. Participation of communities will be a key to the success of the project, so building their stewardship capacity will be important.

Resp: Both Status: In Progress

Stage: Both Recurrent:

Due Date:

Frequency:

Risk Management:

Close technical support has been provided by the World Bank team to enhance the client's knowledge on World Bank procedures. This will be further strengthened during the remaining preparation stage as well as implementation stage. For fiduciary aspects, the country office Financial Management and procurement experts are providing day to day support.

Resp: Bank Status: In Stage: Both Recurrent: Due Frequency

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Progress

Date: :

Implementing Agency (IA) Risks (including Fiduciary Risks)

Capacity Rating Substantial

Risk Description: While they exist, limited number of competent staff, especially for fiduciary management in the country, may reduce the efficiency of project implementation. Monitoring of results may also be a challenge, as the existing health information system is fragmented and dysfunctional. Coordination difficulties between technical staff (different Programs and Divisions within the Ministry involved in the project) and the project implementation team may also result in implementation delays. Limited knowledge of World Bank policies and procedures and difficulty in harmonization with the national guidelines (especially since adoption of national procurement guidelines).

Risk Management:

A preliminary fiduciary capacity assessment of the MoH staff (both for financial management and procurement) was conducted. While there are some conditions, with adequate training and supervision, it was judged that these staff will be able to meet the minimum fiduciary requirements of the Bank. The Project Preparation Advance (PPA) request was submitted by the government which will allow them to jump start with recruitment of adequate personnel, train them and put in place adequate mechanisms (preparation of plans, establishment of accounting tools etc.) by the project effectiveness.

Resp: Client Status: In Progress

Stage: Both Recurrent:

Due Date:

March 1, 2014

Frequency:

Risk Management:

The Project implementation unit (PIU) will be placed under the direct supervision of the Ministry's General Directorate, and a Project Coordinator was nominated to lead the team on the basis of (i) his competence to coordinate across different divisions within MoH and other Ministries and (ii) his management skill and knowledge on public health. International experts on FM, procurement and M&E will be recruited at least at the initial stage of the project. They will be accompanied by national ''secondees'' who will be selected on a competitive basis for each role. There will be a concrete competence transfer plan for each ''secondee' with regular evaluation of their level of competence, in order to ensure that capacity is sufficiently built within the Ministry.

Resp: Client Status: Not Yet Due

Stage: Both Recurrent:

Due Date:

Frequency: Quarterly

Risk Management:

Project's procedural manual will be developed during the preparation phase. An external consultant was identified and is in the process of being recruited. A technical group was set up within the Ministry (including representatives of different Programs/Divisions within the Ministry as well as staff already sufficiently trained in fiduciary aspects) to work with the Consultant for the development of the manual.

Resp: Client Status: In Progres

Stage: Preparation

Recurrent: Due Date:

March 1, 2014

Frequency:

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s

Governance Rating Substantial

Risk Description: Current change in the Government (elections) may result in the potential absence of strong leadership and governance structure to facilitate broad based consultations in the decision-making process. Given the large number of actors involved, there may be some level of confusion in the roles and responsibilities, resulting in lack of accountability and adequate oversight.

Risk Management:

The Bank team intends to maintain a continued policy dialogue with them to ensure close coordination.

Resp: Client Status: Not Yet Due

Stage: Preparation

Recurrent:

Due Date:

March 1, 2014

Frequency:

Risk Management:

A Project Monitoring Group was created to provide adequate supervision and oversight. The Committee will include all key stakeholders, especially those from other ministries, such as the Ministry of Finance, various programs and divisions within the MoH, development partners (WHO, UNICEF), the Bank and civil societies.

Project Risks

4.1 Design Rating Moderate

Risk Description: The project design is fully aligned with Government priorities and focuses on bridging any gap in achieving their objectives. While the nature of interventions is rather straightforward, heavy reliance on communities for malaria and nutrition interventions may encounter unexpected difficulties during the implementation phase. This is particularly true for distribution of inputs as well as monitoring of the results. Budget limitation will not allow for large-scale intervention despite the high demand in each of the area that the project intends to support, thus resulting in a limited

Risk Management:

A detailed capacity assessment of actors at local levels (including decentralized level health administrations, community health workers and local NGOs) will be carried out prior to implementation. The project team has also been holding intensive discussions with development partners and NGOs that are already implementing community level activities to learn from their experience. The community activities are also well aligned with the Government strategies for community-based interventions in order to ensure that the design is well aligned with the existing health systems.

Resp: Both Status: Not Yet Due

Stage: Preparation

Recurrent:

Due Date:

March 1, 2014

Frequency:

Risk Management:

In order to maximize the project impact, the project design will build on existing delivery approach, as seen in the integration of malaria control/treatment and prevention of malnutrition interventions in facility-based antenatal and integrated management of childhood illness, and community based approaches. These approaches would reduce transaction costs and also use to the extent possible the existing health system without creating a parallel structure.

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impact. Resp: Both Status: Not Yet Due

Stage: Both Recurrent:

Due Date:

Frequency:

Social and Environmental Rating Low

Risk Description: Risk Management:

The proposed activities are not expected to entail major environmental safeguard issues, except for potential medical waste management related to malaria intervention. As for social aspects, since the main thrust of community-based approaches depend on behavorial changes, particular attention needs to be given at culturally sensitive issues or religious beliefs.

The MoH has already developed a Medical Waste Management Plan (MWMP) with support of WHO and other development partners. However, as this Plan spans the 2010-2014 period, an updated Plan needs to be prepared prior to the project, including (i) updated progress on the implementation status of the Plan; and (ii) address specifically the disposal of LLINs. Cultural issues will be well examined during the preparation phase building on prior experiences on community-based approaches in the country. If deemed necessary, some sort of social assessment can be considered to address specific issues during preparation or implementation.

Resp: Client Status: Not Yet Due

Stage: Both Recurrent:

Due Date:

Frequency:

Program and Donor Rating Substantial

Risk Description: The mobilization of additional resources is highly dependent on Government co-financing or other donor support. However, as donors are still gradually returning to Togo, development assistance in general is very limited, thus resulting in uncertainties with regards to sustainability and scale-up of the project.

Risk Management:

Consultations with key partners were carried out from the initial phase of project preparation to ensure alignment in interventions. During the implementation phase, a good coordination mechanism between different actors will be put in place to ensure synergies and cost efficiency. The establishment of a learning platform for the Government and its partners to share evidence, such as the results and lessons that will emerge from this project, will be considered.

Resp: Both Status: In Progress

Stage: Both Recurrent:

Due Date:

Frequency:

Risk Management:

An emphasis will be put on policy dialogue to ensure that the Bank will continue to support the Government's broader agenda. This is particularly the case for health financing issues; a separate analytical work is envisaged in parallel to this project, once funding has been identified.

Resp: Both Status: In Progress

Stage: Both Recurrent:

Due Date:

Frequency:

Delivery Monitoring and Rating Substantial

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Sustainability

Risk Description: Neither lack of counterpart funding nor a cost recovery mechanism may undermine the ownership and commitment of the Government to continue the activities beyond project closure.

Weak traceability of the existing supply chain mechanism especially under regional levels (districts and peripheral) may undermine project performance for distribution of drugs and bednets.

Risk Management:

The project is designed to address the critical shortage of inputs, while at the same time support strengthening of the health system itself to ensure the longer-term capacity of the Ministry.

Resp: Client Status: Not Yet Due

Stage: Both Recurrent:

Due Date:

Frequency:

Risk Management:

An in-depth assessment of (i) the existing capacity of supply chain mechanism, especially at the district and peripheral levels, (ii) the central drug procurement agency, and (iii) storage capacity will be crucial in determining how to acquire and distribute the inputs under this project. The use of UN agencies with adequate capacity and experience (at least in the project's early phase) is also considered.

Resp: Both Status: Not Yet Due

Stage: Both Recurrent:

Due Date:

Frequency:

Risk Management:

Staff capacity building complimented by on-the-job training and regular supervision will be carried out.

Resp: Client Status: Not Yet Due

Stage: Implementation

Recurrent:

Due Date:

Frequency:

Overall Risk

Overall Implementation Risk: Substantial

Risk Description:

Implementation stage risk also remains as Substantial and the risks identified by the project team holds: (i) weak fiduciary management capacity of MoH given the long absence of donor-funded projects; (ii) lack of clarity in the roles and responsibilities of actors involved given that there are many actors both at central and decentralized levels; (iii)weak capacity in the area of M&E and quasi-inexistent health information systems; and (iv) poor supply chain management of drugs and other inputs with poor traceability beyond regional levels. Governance risk may also arise depending on the level of leadership of the Government.

Note : Include on average no more than 3 Risk Management Measures per Risk Category

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Annex 5: Implementation Support Plan

TOGO: Maternal and Child Health and Nutrition Services Support Project Strategy and Approach for Implementation Support 1. The Implementation Support Plan (ISP) is particularly important in the context of this project given that: (i) as outlined in the ORAF, both risks for preparation and implementation are currently rated as substantial, and implementation of appropriate risk mitigation measures should be ensured; and (ii) the World Bank was absent for a long time in the health sector and implementing agencies would require significant technical support to ensure that the project development objectives are achieved. 2. From the onset, the task team included, in addition to the task team leader, technical experts for each of the three main areas (malaria, nutrition and HMIS), an Operations Officer, fiduciary experts and safeguards experts. Preparation missions were conducted in the presence of all team members, thus allowing for an in-depth discussion with the Government and partners to ensure full alignment with their strategies and activities. 3. The implementation support plan will rely on the detailed preparation of project activities and implementation arrangements (especially for the design of community level activities), decentralized supervision wherever possible; close monitoring of indicator progress and appropriate fiduciary oversight. Close follow-up and technical support of each subcomponent is also crucial for the success of the project.

• Technical: Extensive technical support will be provided by the Bank on a continual basis

and in particular during the early stages of implementation of malaria and nutrition-related interventions through a community-based approach. Specific attention will be given to the incentive payment of CHWs (especially the performance-based payment pilot initiative to be designed and tested in the Centrale and Plateaux regions) and M&E. Support will also be provided on all operational aspects of project implementation.

• Procurement. Implementation support will include: (i) strengthening the project implementation team with the recruitment of a Procurement Specialist and the nomination of a civil servant as procurement officer who must be full time devoted to the project procurement activities; (ii) providing appropriate training as needed; (iii) reviewing procurement documents and providing timely feedback; (iv) providing detailed guidance on the Bank’s Procurement Guidelines to the implementing agencies (IAs); and (v) monitoring procurement progress against the detailed Procurement Plan.

• Financial management. Implementation support will include: (i) reviewing of the country’s financial management system, including but not limited to, accounting, reporting and internal controls; (ii) hiring additional staff and providing training as needed; (iii) reviewing submitted reports and providing timely feedback to the IAs; and (iv) ensure that appropriate funds flow are maintained, especially at decentralized levels.

• Environmental and Social Safeguards. The Bank team will supervise the implementation of the agreed MWMP and provide guidance to IAs and Government.

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• Other Issues. Sector level issues related to the project will be addressed through policy dialogue with the MoH and other ministries concerned. This will include in the immediate term a discussion on financial sustainability, implementation of activities at decentralized levels, particularly community level interventions, and availability of inputs (especially for malaria beyond 2016 when GFATM closes their activities). The Bank team will support the client in carrying out analytical work wherever appropriate to inform policy decisions.

Implementation Support Plan

4. The Bank team members will be based either in Washington DC or in Country Offices and will ensure availability to provide timely, efficient and effective implementation support to the client. However, given the lack of experience with World Bank projects in Togo, it is advisable to have a Health Specialist based in Togo at least for the initial years of the project to oversee project implementation on a daily basis, both from a technical and operational perspective. Formal supervision and field visits will be carried out on a quarterly basis during the first two years, with a detailed Mid-Term Review to be planned in the beginning of the third year. Detailed inputs from the Bank team are outlined below: • Technical inputs. Intensive technical support will be provided by World Bank experts to

ensure that the activities are implemented in the most cost-effective way and in accordance with the project development objectives, and that they are fully aligned with the Government strategies and other partners’ interventions.

• Fiduciary management. Training will be provided by the Bank’s FM and procurement specialists as needed. The Bank team will also help identify capacity building needs to strengthen FM capacity and to improve procurement management efficiency. The World Bank’s FM and Procurement Specialists will be based in the region to provide timely support. Formal supervision of financial management will be carried out semi-annually, while procurement supervision will be carried out on a timely basis as required by the client.

• Safeguards. Inputs from environment safeguards specialists will be provided as needed; especially to supervise the implementation of the MWMP.

• Operational. The task team will provide day to day operational support in order to ensure timely implementation of the planned activities and to monitor progress towards achievement of the project’s development objectives.

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Table 5:1: Project Implementation Support Plan Time Focus Skills Needed Resource Partner Role

First 12 months

Project effective start-up, including completion of key procurement, implementation arrangement set-up design of the CHW incentive arrangement, recruitment of implementation team staff and training.

Technical expertise on malaria, nutrition and M&E to implement project activities. Strong operational support, fiduciary management and M&E to ensure effective start-up and implementation. Strong expertise on health economics to ensure policy dialogue on health financing.

IDA Development Partners for leveraging resources, ensuring complementarity with their activities, experience and knowledge sharing. Potentially also involvement of local NGOs and communities to ensure activities are adequately implemented at community levels.

12-48 months Intensive support to ensure effective implementation. Adaptation of implementation strategies as appropriate. Ensuring satisfactory progress towards achieving project goals and objectives.

Same as above Same as above Same as above

FM implementation Support 5. Supervision will focus on the status of FM system to verify whether the system continues to operate well and provide support where needed. It will comprise inter alia, the review of audit reports and IFRs, advice to task team on all FM issues, review of annual audited financial statements and management letters. Based on the current risk assessment which is Substantial, there will be two on-site supervision missions per year during implementation, and a review of transactions will be performed on these occasions.

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Table 5.2: FM Implementation Support Plan Based on the outcome of the FM risk assessment, the following implementation support plan is proposed. The objective of the implementation support plan is to ensure the project maintains a satisfactory FM system throughout the project life. FM Activity

Frequency

Desk reviews Interim financial reports review Quarterly

Audit report review of the program Annually

Review of other relevant information, such as interim internal control systems reports.

Continuous as they become available

On site visits Review of overall operation of the FM system Quarterly for the first 2 years;

biannual for the rest (Implementation Support Mission)

Monitoring of actions taken on issues highlighted in audit reports, auditors’ management letters, internal audit and other reports

As needed

Transaction reviews (if needed) As needed

Capacity building support FM training sessions During implementation, and as and

when needed.

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Table 5.3: Procurement Implementation Support Plan 6. The following Procurement implementation support plan is based of procurement capacity assessment and formal requirement for project implementation.

Activities objective Period/ Frequency

Resource Estimate

(US$)

Responsable

Nomination of a civil servant as project procurement officer

Strength the MoH procurement capacity through the training of at least one ministry high level staff (knowledge transfer)

Before effectiveness

N/A MOH

Recruitment of a Procurement Specialist

Strength the MoH procurement team and capacity with a staff skilled with Bank’s procurement procedures and Guidelines

Before effectiveness

Project/IDA MOH, WB

Organized one week procurement training for MOH procurement staff

Train key staffs involved in procurement process in the MoH and its Projects implementation agencies staffs

First 12 months after project effectiveness

Project/IDA Bank’s Procurement specialist (PS), MOH, WB, DNCMP

External training for project’s key procurement staff

Inform and advice procurement staff on external training opportunities in agreed procurement training centers, and allow with the TTL the participation of MoH main staff involved in project procurement process.

12-48 month after project effectiveness

Project/IDA WB (PS & TTL), MOH

Procurement documents reviews

Ensure the quality of bidding documents and evaluation reports (prior review)

Each time, during project implementation

N/A

Bank’s Procurement specialist in country office

Procurement post review

Review procurement process, identify procurement weakness and made recommendations (action plan) for improvement

Annually during project implementation period

N/A

Bank’s Procurement specialist in country office

Procurement Plan monitoring

Assess the level of procurement plan implementation and provide guidance for improvement identify and remove bottlenecks

Semi-annually during project implementation period

N/A

Bank’s Procurement Specialist in country office

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M&E implementation support 7. The project aims to support the development of a comprehensive M&E system. Initial discussions with the client permitted to define the scope of this support, and its implementation will require continuous technical assistance. This support will be provided through external assistance (individual consultant or consulting firm to be decided in collaboration with the client) and will include the elaboration and implementation of a detailed M&E development plan. Although the specific needs for implementation of the M&E plan will be further developed with the client, the following support will be required at the initial stage: Develop the TORs for the long term technical assistance to support elaboration of the M&E

plan (preferably to be based at the M&E department of the MoH); Development and review of essential M&E documents to be developed with support of the

TA; Updating and duplication of data collection tools; Training of data collectors (health facility and community level); and Introduction of DHIS2 at the central and district levels, training of end users, etc. 8. The recruited TA will provide technical support to design and develop the M&E system. The Public Health Specialist will work closely with the client as well the external TA to ensure quality of the design and smooth implementation of the agreed plan.

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Annex 6: Economic and Financial Analysis

TOGO: Maternal and Child Health and Nutrition Services Support Project

A. Economic and Financial Analysis

1. There is strong economic rationale for investing in maternal and child health (MCH) and nutrition in Togo. Evidence from various sources39 shows improvement over time in access to and utilization of some essential MCH services, nutrition supplements, malaria during pregnancy, and related health outcomes. For example, the 2010 MICS shows that about 46% of pregnant women sleep under insecticide treated net (ITN) and half of them receive intermittent preventative treatment (IPT) for malaria during pregnancy (MICS 2010). As for nutrition, exclusive breastfeeding has increased to 63% for infants less than six months of age (MICS 2010). Vitamin A supplementation for under-five children – which is shown to have reduced all-cause mortality by 24% and diarrhea-related mortality by 28% in children aged 6-59 months (Imdad et al. 2010) – has increased to approximately 90% (MICS 2010; UNICEF 2012). Maternal mortality has declined from 570 per 100,000 live births in 2000 to 350 in 2010 (MICS 2000, 2010).

2. Yet, several indicators have failed to show sufficient progress, adversely affecting the country’s likelihood of reaching the health MDG targets. In fact, Togo’s “unlikely” rating to reach the MDGs is principally due to the lack of sufficient progress in MCH and nutrition outcomes. Infant and under-five mortality have remained stagnant. Although Togo has relatively lower overall stunting (low height for age) rate for under-five children compared to its neighbors and income peers40, this rate has increased from 28 to 30% between 2006 and 2010 (UNICEF 2012; MICS 2006, 2010).

3. Progress is not homogenous for a number of indicators. National averages mask regional, urban-rural, and socio-economic disparities (WHO 2010; MICS 2010; UNICEF 2012). Hence, (i) designing interventions based on disaggregated data; (ii) using such data for effective resource targeting; and (iii) tracking program performance over time to inform program implementation, including design adjustment and rollout, are critical. The 2010 MDG Report shows that the probability of nutrition-related mortality for under-five children in rural areas is significantly higher compared to their urban peers, and infant and under-five morality rates are above the national averages for three regions: Kara, Savanes, and Centrale (WHO 2010; MICS 2010). These final outcomes and other health statistics are correlated with the incidence and depth of poverty, which show significant variation across urban and rural sectors, and regions (Coulombe 201241). While poverty incidence has reduced between 2006 and 2011 from 61.7 to 58.7% nationwide, it has increased by between 4 and 5 percentage points in the Plateaux, Centrale, and Savanes regions (Coulombe and Male 2012). As poverty is both a cause and the result of poor health status, it is important to pay attention to the poverty reduction and economic development aspect of MCH interventions.

39Data sources listed in the Maternal and Child Survival Togo Country Profile (UNICEF 2012) include: DHS 1998; MICS 2006; Other NS 2008; MICS 2010; and WHO 2010. 40 Nutrition at a Glance – Togo 2009 41 This poverty mapping report shows breakdowns based on data from the Questionnaire des Indicateurs de Base du Bien-être (QUIBB 2011) and the Recensement Général de la Population et de l’Habitat (RGPH4).

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4. A number of low and middle-income countries have been exploring the role of performance-based financing (PBF) in improving health outcomes. Togo has not been an exception in considering the feasibility, potential benefits and costs of this innovative approach. PBF is an intervention that is gaining significant momentum as a solution to poor performance and the health worker crisis in low-income countries, particularly in Africa. Results indicate that PBF can play a role in increasing the productivity of health workers and have positive effects on health service utilization. However – given the novelty, heterogeneity, and context-specificity of PBF – to date the evidence base has been limited, especially in the context of community performance-based financing (C-PBF), where the incentive scheme design goes beyond the facility staff and must include considerations regarding community dynamics. Hence, in general, any project that considers a PBF component requires careful design and piloting of the proposed incentive scheme. To inform design, implementation, and policy decisions operational research, it is critical to gather evidence on the effectiveness, cost-effectiveness, and equity implications of PBF interventions. The project is not currently designed to use this mechanism. However, there is evidence of a recent change in regard to the GoT’s view on this issue, and the project will explore the possibility of providing support through policy dialogue and AAA activities, as needed, to help inform the GoT’s evolving position on PBF.

5. The assessment of the macro-fiscal and health care financing context shows mixed results. On the one hand, by 2010, the trend lines for the fiscal context, including debt, fiscal deficit, revenue, and spending show improvement (see Figure 6.2). On the other hand, the decomposition of sources of revenues suggest that while other taxes as a share of GDP have been increasing, income tax has declined and donor dependency has increased to above the regional average. Although increasing donor assistance adds to fiscal space, it carries the risk of volatility of aid flows, which can affect the economy and, more specifically, the health sector. With respect to macro indicators, increasing economic growth is encouraging as real GDP growth affects general Government expenditures, and, consequently sectoral budget allocations. The health care financing trend lines show improvement, with increase in total health expenditures as a share of GDP (THE/GDP), commitments to the health sector budget from general Government expenditures (GHE/GGE), a growing share of public financing and, consequently, reducing out-of-pocket payments by 2010 (see Figure 6.3 in Annex 6. C). However, an analysis of the direction and size of the output gap for GDP, general Government expenditures (GGE) government health expenditures (GHE) (see Table 6.3 in Annex 6. C), and trends of cyclical components for the same variables show that, between 1995 and 2010, the health sector was relatively more exposed to volatility in economic performance (see Figure 6.3 in Annex 4. C). In general, such statistics would imply that the health sector budget is subject to more than proportionate downward adjustment during economic downturns, that is, the predominant response is procyclical. In fact, bivariate correlation coefficient for cyclical patterns between key variables of interest between 1995 and 2010 show significant positive correlation, especially during times of negative output gap (i.e. when economic performance is below the filtered trend line). The conclusion from macro level data is that, while there is an overall conducive environment for financing critical interventions, volatility of donor contribution can adversely affect the sector, especially if procyclical reflexes remain. At the micro level, while there is not enough data to quantify sustainability at this stage, evidence from low-income context suggests that MCH and nutrition interventions are not only effective and cost-effective, but that the

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proposed community-based platform could save resources, if it serves as a lower-cost alternative in providing malaria treatment and nutrition services.

B. General Economic Rationale for MCH and Nutrition Interventions

6. The effectiveness and economic benefits of maternal and child health and nutrition interventions - which are thoroughly studied and well documented in developing countries- go well beyond the health sector. Economic analyses point out that these interventions not only have a significant effect on the target population’s health status, but through the channels of education and labor productivity, they affect the individual’s lifetime earning potential and can lead to positive inter-generational wealth and poverty-reduction effects at the household level. Such economic effects at the micro level reflect in the country’s macroeconomic performance, measurable in changes in the GDP.

7. Despite increased attention to maternal mortality and the availability of proven, high-impact interventions to address poor maternal health, health systems and current financial commitments for maternal and reproductive health in a number of LICs in Africa may not be sufficient to achieve the MDG 4 and 5, which focus on maternal and child mortality. MCH services constitute an integrated continuum of care that delivers essential services and interventions to women who face particular risk arising from reproduction and pregnancy, their infants at critical points, and to children in their first five years of age. The continuum of MCH care is fundamental to development, which is reflected in MDG 4 (reducing under-five child mortality by two-thirds between 1990 and 2015) and 5 (reducing maternal mortality by three quarters between 1990 and 2015 and achieving universal access to reproductive health by 2015). Globally, nearly 10 million women per year who survived childbirth suffer from pregnancy related injuries, infections, diseases and disabilities, often with lifelong consequences. Research has shown that 80% of these deaths could be averted if women had access to essential maternity and basic health care services. As part of the service continuum, reproductive health, including family planning, saves infant lives by spacing planned births and limiting unintended births. Family planning also saves maternal lives by reducing exposure to the risks of pregnancy and childbirth, including recourse to unsafe abortion, one of the main causes for deaths among young women.

8. Maternal mortality has a significant negative impact on economic growth through various pathways, including its effect on the size of the labor force and adverse effect on human capital formation, and hence, levels of GDP. As mothers play a prominent role in the production of household food, their premature death may have a negative effect on children’s nutritional status which, in turn, can affect their physical and cognitive development. One study that estimates the effect of maternal mortality on GDP in Africa shows that maternal mortality has a statistically significant negative effect on per capita GDP. An increase in MMR by one death decreases per capita GDP by US$0.36 per year on average. This estimate is a lower bound as the model does not capture the true effect of maternal mortality on GDP because of its static nature, which does not allow capturing the intergenerational effect of maternal deaths on infant deaths, future productivity, and the loss in prospective human capital; in addition, the contribution of mothers to GDP is excluded, given that most of them are typically full-time home makers or work in the informal sector.

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9. Maternal and childhood nutrition has a substantial effect on economic growth, as underscored in the Copenhagen Consensus (2012), and this is particularly relevant in low-income countries where nutrition is at the heart of economic development and poverty reduction efforts. Better nutrition increases the productivity and, thus, economic growth through increased labor supply. The productivity losses by malnutrition occur through three pathways: direct loss of physical productivity, indirect loss from loss in schooling and poor cognitive development, and losses from high use of health care resources. For example, a 1% loss in adult height as a result of child stunting is associated with a 1% loss in productivity. Anemia is associated with a 2.5% of reduction in wages. Productivity losses at the individual level are estimated to be more than 10% of life time earnings, which at the macro level can lead to a 2-3% loss in GDP. The economic benefits of improved nutrition come from reduced infant and child mortality, and reduced health care cost for sick children. Substantial benefits accrue from productivity gain due to physical stature, as well as from increased schooling performance and cognitive ability, which affects lifetime potentials. Based on very high cost-effectiveness ratios, the Copenhagen Consensus concluded that out of 30 potential development investments, interventions to reduce undernutrition in preschoolers are the best way to advance global welfare.

10. Despite the proven effectiveness of the economic impact of MCH and nutrition interventions, the benefits of these services do not adequately reach the target groups in Togo because of both supply and demand side constraints, which include availability and quality challenges (supply side) and physical and financial access to care (demand side). Market failures stem from information asymmetry between provider and target beneficiaries, which can be of two kinds. First, beneficiaries may not have adequate access to information about technologies and services, leading to incomplete or incorrect information. Second, even if beneficiaries have information, they may not realize the value of the service and, hence, may opt out from utilization. This phenomenon is discussed in the economic literature under market failure related to merit goods and related public economic considerations for either improving the environment for disseminating information that could induce behavior change or providing price signals through subsidies. In the case of malnutrition, although both the private and social returns to improved nutrition are recognized and high, malnutrition has continued to persist. This is because poverty imposes a constraint on households to invest more resources in children. Information asymmetry in the context of nutrition can take place either because mothers do not know when the child becomes malnourished and only start acting by the time the condition is severe, or because good nutrition practices are not known and, hence, they do not provide the right mix even when they could afford it. Beyond the public good nature of nutrition interventions, which accrue benefits to the whole society, the economic impact and redistributive effects of investing in nutrition provide a clear argument for public intervention in this area.

11. To address these challenges and meet the proposed PDO (increasing utilization of selected MCH services for pregnant women and children), the project proposes to build on and reinforce existing health service delivery platforms (ANC, IMCI, and community-based delivery).

Community-based service delivery has been attracting considerable policy attention

in low-income countries as an instrument that could bridge some of the health care

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access and outcome gaps that unduly and adversely affect many of the poor and vulnerable. Community- and family-based approaches have been identified in the demographic and public health literature as one of the key factors promoting improvements in health, even under very poor economic conditions. Different mechanisms have been suggested as driving forces behind the impact of community-based approaches, including behavioral change communication, easy access to primary care, and engagement and empowerment of communities in health campaigns and actions. As to empirical evidence, the 2013 Lancet Series on Maternal and Child Nutrition notes that community-based nutrition programs can more than double the rate of initiation of breastfeeding within 1 hour of birth. Further, a review of 82 studies found that community-based health or nutrition workers improved rates of excusive breastfeeding by 2.78 times in contrast with usual care. A number of nutrition tracer statistics in Togo suggests that the community-based approach has plenty of space to boost these outcomes. Beyond the public health literature, recent theoretical and empirical research in economics has been focusing on the broader effects of community-based approaches, including effects on schooling and labor market participation. For example, community-based health interventions may give families access to technologies that were previously too expensive or unknown (e.g. birth control, nutrition practices). In the long run, behavior changes in these areas may increase the return to investment in human capital and attachment to the labor market, leading to broader economic effects.

The community-based approach is expected to generate additional benefits as it can help shift the focus from traditionally supply-side heavy interventions toward the demand side, with the objective to balance incentives that target providers and consumers. Proponents of community-based approaches hold that the strength of this platform is rooted in the use of social capital, mutual trust, and peer monitoring, which reduce transaction costs. The central attributes of community-based mechanisms include decision-making at the local level, proximity to membership, personal acquaintance of the members, empowerment of members by participatory design, autonomous management, and lower-cost management due to reduced agency problems and transaction costs. These attributes aim to foster service desirability and affordability, which are critical for utilization, sustainability, and scale-up.

Beyond pure economic considerations, operational design takes into account the social dynamics and structures that contribute to determine the success of community-based platforms. The social capital model, developed by Woolcock (1998, 2001), was derived from community-level economic development programs in low-income countries. According to this theoretical model, social capital is productive, making possible the achievement of social targets by leveraging trust, trustworthiness, structures, norms and effective sanctions that can prevent unproductive behavior among individuals. Empirical studies in the context of agriculture and water and sanitation suggest that higher levels of social capital are positively correlated with improved development outcomes. In the context of health, social capital is associated with a lower degree of inequality, including smaller health disparities and less segregation. The main results of empirical studies to date show that both individual social capital and community social capital are – when taken separately – correlated with health. As such,

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the economic return on community-based heath interventions could be associated with social structures.

12. The expected economic benefits of the project in terms of lives saved and economic gain are shown in the table below. These are very preliminary estimates and are based on conservative assumptions regarding, e.g. the GDP growth rate of 5% in 2011.42

Table 6.1: Expected Economic Benefits – Lives saved and economic gain

Malaria Case Management (Component 1.1.) 2014 2015 2016 2017

TOTAL (4 Years)

Total # of Potential Beneficiaries U5 1,111,670

1,143,241

1,175,709

1,209,099

4,639,719

Total # of Potential Beneficiaries O5 6,250,381

6,427,892

6,610,444

6,798,181

26,086,899

Total # of Potential Beneficiaries, Total Population

7,362,051

7,571,133

7,786,154

8,007,280

30,726,618

Total Estimated # of Lives Saved (LS), CFR=3.6/10,000

2,650

2,726

2,803

2,883

11,062

Lower Bound for Economic Gain (LS * GDP/Capita), Current US$

$ 2,401,604

$ 2,593,300

$ 2,800,297

$ 2,966,221

$ 10,761,422

Nutrition services (Component 1.2) Estimates for # of U5 Lives Saved (LS)

during Project Due to Nutrition-Related Mortality

1,722

617

684

756

3,779

Lower Bound for Economic Gain (LS * GDP/Capita), Current US$

1,560,181

586,734

683,805

777,537

3,608,257

TOTAL ECONOMIC GAIN

3,961,785

3,180,034

3,484,103

3,743,758

14,369,680

13. Total expected lives saved would be 14,841, and there would be a conservative economic gain of US$14,369.680 at the country’s 2011 growth rate of 5%, giving a benefit to cost ratio of 1.03, or a benefit of just over a dollar for every dollar invested.43

C. Subcomponent-Specific Economic Rationale: Malaria and Nutrition Services COMPONENT 1: Improved utilization of malaria and nutrition services (US$10.0 million) Subcomponent 1.1: Support for (i) malaria control in pregnancy through contribution to a minimum package of services through ANC; (ii) community-based diagnosis and treatment of

42 As the context section shows, there may be reasons to be more optimistic about the growth prospects as the rate of growth has been increasing since the period of political crisis. Therefore, the benefits calculated may be considered to be on the lower side. 43 However, it is important to stress that these figures, for now, underestimate significantly the expected benefits of the project, as we did not take into account any savings on the system side, which could be substantive, given significant expected investment there, nor did we account for opportunity cost reduction or externalities on other household members, not to mention longer term effects. As more data becomes available, this analysis will be updated to take these effects into account.

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ITN & IPTp for Pregnant Women

Increased Coverage

Increased Utilization

Reduced Clinical Malaria (Severe

Malaria)

Reduced Maternal Anemia

Reduction in Low Birth Weight

Reduction in Maternal & Infant/Child

Mortality

Economic Implications

through Other Pathways

malaria; and (iii) management, supervision, and behavioral changes to ensure effective utilization (US$7.0 million)

Economics of malaria control in pregnancy

14. Although malaria in pregnancy is a major public health problem, its economic impact is not well documented. A systematic review finds that, while interventions are cost-effective, coverage is inadequate and fails to reach the poor (Worrall et al. 2007). The study emphasizes that current evidence does not reflect the true effect of malaria burden during pregnancy since they do not account for the full direct, indirect, and opportunity costs at the levels of the household and providers; they also fail to account for mother-to-baby, long-term, and intergenerational effects.

15. The causal pathway of the effect of the intervention is illustrated in Figure 6.1. This pathway shows that increased coverage and utilization of ITN and IPT by pregnant women is expected to reduce clinical malaria, including severe malaria. Severe malaria and malaria related severe anemia may result in maternal death or adverse pregnancy outcomes, such as spontaneous abortion, neonatal death, and low birth weight, which are among the leading causes of poor development (Desai et al. 2007). The main effect of infection in stable malaria transmission areas is malaria-related anemia in the mother and presence of parasites in the placenta, which impairs fetal nutrition and, hence, contributes to low birth weight (Desai et al. 2007). In Africa, malaria-related low birth weight has a fatality rate of 37.5% and is responsible for at least 13 percent of malaria mortality in children under five years of age (Murphy and Breman 2001). The economic benefit of reducing the incidence of low birth weight in newborn babies is estimated at US$510 per new born baby (Alderman and Behrman 2006). The economic benefits of malaria control during pregnancy include externalities on the infant as well as long-term cognitive effects. With respect to effect of years of lives gained (YLG), maternal and infant mortality is correlated as the death of a mother increases the child’s risk of death within the first year of life, especially for female children (WHO 1994). Regarding long-term economic implications, one study found that children born with low birth weight were more likely to experience failure at school (Sachs and Malaney 2002). Low performance in school can lead to reduced life time earning potential and may even have intergenerational effects.

Figure 6.1: Causal pathway of malaria prevention during pregnancy and outcomes44

16. As to empirical evidence from Africa, in Uganda a non-randomized community trial of 2,081 pregnant women has shown that using community-based delivery, 67.5% of women accessed IPTp in the second trimester and adhered to two doses of SP. Similarly, the use of ITNs increased from 7.7 to 22.4%. Community outreach also positively affected routine facility-based care. For example, the proportion of women seeking malaria treatment at health units increased from 16.7 to 36%; ANC (four visits) increased from 3.4 to 56.8%; and the proportion of women delivering at health units increased from 34.3 to 41.5%. However, the combined effect of IPTp

44 Own illustration based on Worrall et al. (2007).

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and ITN is not fully understood as most studies of IPTp were done before widespread ITN use. One study, implemented in the Gambia, has shown that IPT alone has a greater effect than ITN alone, and there is a small additional benefit of combining IPT with ITN. ITN remains important in malaria control during pregnancy because the joint use of nets by both mother and baby lead to compounded economic benefits.

17. Because of data limitations and challenges to account for indirect and opportunity costs and as a result of externalities and long-term effects, calculating the economic cost and benefits of malaria during pregnancy is not easy (see Table 6.1). In general, studies that rely on project level data and use intervention specific costs only take into account costs that accrue to the Government or the provider, and these are highly aggregated. Such costing does not take into account household level expenditures, which require (target) population representative survey data. In principle, a combination of project and micro-level data from the facility, household, and community level is necessary to estimate costs more accurately. Such detailed costing, however, requires advanced planning for surveys and budget for evaluation.

18. With respect to benefits, the project can rely on process indicators, such as PDO level indicators and the project impact defined in terms of cases averted or years of life gained. This requires using assumptions on effective coverage and efficacy as well as drawing on earlier evidence and expert assessment on effectiveness. Alternatively, existing population-level survey data, such as DHS and MICS, can provide statistics on baseline levels of selected key benefits. Beyond improved accuracy, micro data has the additional benefit that it provides estimates below the national level, which is critical, given the variations in MCH, malaria, and nutrition outcomes both across and within regions as well as districts. As adjusting both costs and benefits estimates for regional variation can alter the results of cost-effectiveness analyses, such information is valuable for project design and implementation. Consequently, as part of Component 2, which aims to improve the monitoring of MCH programs, the evaluation framework proposes to include data collection for cost-effectiveness analysis and related analytical work45.

Table 6.2: Matrix of the economic impact of malaria during pregnancy - costs and benefits

45 It will be interesting to do a cost-effectiveness analysis of the project and//or some elements of the project (e.g. comparative advantage of the community-based approach to ensure better coverage of the target groups). This can be done as a specific ESW under the project.

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Community-based biological/parasitological diagnosis and treatment of malaria

19. Malaria and pneumonia are leading causes of morbidity and mortality among under-five in Sub-Saharan Africa (Black, Morris, and Bryce 2003; Black et al. 2008; Kinney et al 2010) despite the availability of cost-effective interventions for both conditions. Community case management of malaria and pneumonia has been shown to reduce under-five mortality (Kidane and Morrow 2000; Sazawal and Black 2003), and this approach is recommended by WHO (WHO 2002; 2004). Further, given the overlap in symptoms between malaria and pneumonia, WHO and UNICEF recommended integrating community case management (iCCM) of these two febrile conditions in endemic areas in low and middle-income countries (WHO/UNICEF 2004). 20. Parasitological confirmation before administering antimalarial treatment was recommended by WHO because of increasing the drug resistance of malaria parasites to antimalarial drugs; in addition, the cost of the first-line treatment (ACT) significantly exceeds the unit costs of drugs used previously to treat malaria. By providing parasitological confirmation of malaria cases, the introduction of RDTs addresses three critical challenges. First, RDTs improve febrile case management and reduce the risk of increasing drug resistance. Second, using RDTs, the biological targeting of ACT to patients confirmed for malaria improves the cost-effectiveness of febrile case management. Consequently, more effective resource targeting affects health sector budgets. Third, as microscopy is not available in many facilities and is not practical in terms of reaching populations in remote locations, RDT offers an alternative diagnostic technology (comparable in sensitivity to routine microscopy; see, e.g. Murray et al. 2003; Harvey et al. 208) that can reach vulnerable populations who, otherwise, would not have benefited from biological diagnosis, increasing the risk of providing them inadequate treatment.

21. Several studies have shown that CHWs can use RDTs safely and effectively (Harvey et al. 2008; Elmardi et al. 2009; Yasuoka et al. 2010; Mukanga et al 2011). A multi-country study (Burkina Faso, Ghana, and Uganda), which explores the effectiveness of diagnostic tests in the context of integrated community case management of febrile children, shows that compliance with RDT results is high (only 4.9% of RDT negatives were treated with ACT) and, hence, RDTs limit the overuse of ACTs (Mukanga et al. 2012). In Tanzania, based on a clinical trial of 2,425 patients that was carried out in three different transmission settings, at moderate to low levels of malaria transmission RDTs were more cost-effective46 than microscopy and both more so than presumptive treatment, but only where responses were consistent with results (Lubell et al. 2010). Improving diagnostic methods can reduce costs but only if compliance with test results are improved. Similarly, Shillcutt et al. (2008) shows results from a decision tree analysis with probabilistic sensitivity analysis applied to outpatients presenting at rural health facilities with suspected malaria. Costs and effects are calculated for positive and negative RDT results and consequent treatment with ACT or antibiotics. The cost-effectiveness reflected improvements in health outcomes for non-malaria febrile patients, plus savings in anti-malarial drug costs. However, results are dependent on provider compliance. In a study in Tanzania, Lubell et al. (2007) find microscopy relatively more cost-effective compared to RDTs. However, given the higher sensitivity and specificity of RDTs, they do generate incremental benefits (higher share of

46 The analysis uses a cost-benefit framework, taking a societal perspective, accounting for provider costs and the monetary value of years of life lost, owing to incorrect diagnosis and incorrect treatment.

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patients correctly diagnosed). Further, the operational advantage of RDTs, namely, that they are portable, require less training, can be used outside the facility, make RDTs particularly relevant for case management in low-income settings.

22. However, most studies note that cost-effectiveness is sensitive to behavioral responses, such as provider and consumer compliance. Hence, tracking behavioral responses and introducing interventions (e.g. provider training, reminders, IEC for consumers to reduce information asymmetries, etc.) to encourage utilization of RDTs and compliance with test results can be valuable.

23. In Togo, given that approximately 60% of the population is rural, and that a high share of communities live more than five km from a health facility (for example, 60% in the Plateaux region), the introduction of community-based malaria case management can lead to significant improvements in malaria-related health outcomes and economic benefits at the level of households, which can affect the economy overall. The current low baseline values of parasitological confirmation of malaria and low rates of treatment with the first-line drug (ACTs) (9.5% for children under five, MICS 2010) imply that there are significant benefits to gain as a result of this intervention.

24. In addition to the general and country-specific economic rationale for investing in MCH interventions presented earlier, Tables 6.1 and 6.2 provide quantitative information on the economic benefits related to the malaria intervention of subcomponent 1.1.

25. Although due to data gaps the quantitative presentation is partial, the estimates presented corroborate earlier findings that the proposed investments are not only health improving, but that they also generate significant economic gains in the short- and long-run.

26. Table 6.1 provides the estimated number of beneficiaries, respectively, for (i) ANC-based malaria prevention during pregnancy, including for assumed effective coverage rates of ANC, IPF for malaria during pregnancy, and LLINs as well as beneficiary estimates that are adjusted for utilization patterns (e.g. LLIN use) based on population-level data from MICS 2012; (ii) malaria case management, broken down into under and over-five target groups; and last, for (iii) case management using biological diagnosis and first-line drugs delivered through the community-based platform47. These estimates are provided for each year of the project horizon (2014 through 2017) as well as aggregated for the four years48.

27. Due to data gaps on baseline level malaria-specific maternal anemia and low birth weight, and due to the difficulty in isolating the effects of IPT and LLIN on malaria-related maternal and child morbidity and mortality, we do not provide effectiveness estimates (e.g. in terms of cases prevented, morbidities reduced, or lives saved) for this intervention. However, 47 Estimates for the beneficiaries of the community-based platform are based on the assumption that rural populations who live more than five km away from a facility are the primary target group. Data from Index Mundi (accessed 2013, estimates for 2010) show that the rural share of the population is 60%. Statistics from the MOH from one region provide estimates of 55 percent for the average population share that live beyond 5 km from a facility. These assumptions are used to calculate the beneficiary estimates for the community-based component. 48 Note, however, that the aggregate number does not take into account repeated pregnancies by the same woman or repeated malaria episodes by the same individual over time and, thus, may somewhat overestimate the effect.

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earlier evidence from Togo shows that purely through mass distribution of LLINs between 2004 and 2005, moderate to severe childhood anemia49 was reduced by 28% (Terlouw et al. 2010). Studies that explore the use of IPTs and LLINs during pregnancy report on intermediary outcomes, such as increase in the coverage rate or utilization, but fall short of providing estimates for cases prevent, morbidity reduction, and lives saved. Hence, data gathering will be important to better quantify the effect of this subcomponent and assess its cost-effectiveness.

28. Table 6.1 provides estimates for lives saved (LS) in the two groups -- under and over-five populations-- through malaria case management with first line treatment. The estimates are calculated using case fatality rates (CFR) from published literature.50 Using the lower-bound estimate51 from Murray et al. (2012), and assuming treatment efficacy of 90%, the estimated number of lives saved in the under-five group is 7,934. For the over-five population using the lower bound estimate52, assuming 90% treatment efficacy, the total number of lives saved is 9,391. Hence, the total number of lives saved in the target population over four years is estimated at 17,32553.

29. Further, the table presents rudimentary estimates for the economic benefits associated with these lives saved. These economic estimates are lower bounds since they only account for a direct benefit – the monetized economic activity by the individual whose life was saved. As a simplifying assumption, we used annual per capita GDP to impute a monetary value for the economic gain. In a static, short-term context, economic benefits are calculated for each year by multiplying the number of lives saved by the annual per capita GDP54. This calculation shows an economic gain of approximately US$3.8 million in 2014, which increases to around US$4.74 by 2017. The total monetized benefit derived from the economic activity of the individuals saved over the four years is estimated to be around US$16.95. As the “total lives saved” includes under-five and other economically inactive, these estimates are upward biased. However, it is important to note that this simplified calculation does not take into account a number of additional economic benefits, including the economic benefits obtained by reducing negative externalities on households or through supply side reduction in economic costs of malaria treatment, and so forth. Further, these calculations only factored in the effect of the project during its four-year project timeframe while it is well-known that the economic benefits of malaria treatment affect the medium to long-term horizons. For example, each individual saved contributes to the economy until his/her death.

30. To illustrate the magnitude of potential gains beyond the project timeline, we also calculated discounted economic gains over the life time. Due to data limitations on the average age for malaria-specific mortality for over-five, we focused on the economic gains generated by

49 The effect was seen predominantly by children aged between 18 and 59 months. 50 The main sources for CFR estimates are a global study of malaria mortality between 1980 and 2010 by Murray et al. (2012), and Togo-based data from Est Mono district between 2005 and 2010 by Landoh et al. (2012). 51 This assumes that for under-fives the CFR=1.9/1,000. 52 This assumes that for over-fives the CFR=4/1,000. 53 As noted before, the aggregate number does not take into account repeated malaria episodes by the same individual over time and, thus, may somewhat overestimate the effect. Nevertheless, the effect remains economically significant, even if repeated episodes by the same person are accounted for. 54 The calculations use current GDP. In line with IMF projections (WEO 2013), a 5% annual GDP growth is assumed throughout the project horizon.

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saving under five. We ignored that, until around 18 years of age, this cohort is less economically active and assumed that saving a year’s worth of per capita GDP can be applied to obtain rough estimates of the magnitude of the gain over time. This assumption can be defended as the calculations do not factor in the financial effect on households (e.g. expenses related to death, loss of income by other family members), in addition, the economic gains from saving over-five lives is not discussed. Cognizant of these simplifying assumptions, the calculations show that saving one individual would generate a gain of approximately US$55,500 over 53 years55, using a 3% discount rate for the annual per capita GDP56 saved. Using higher discount rates (r) the lifetime economic gain per life saved is reduced to US$43,114 (r=5%) and is as low as US$15,011 (r=10%). Using the estimates for under-five lives saved in each project year, the table provides the total economic gain if lifetime gains are considered. For example, it shows that, even when using as high of a discount rate as 10%, the lifetime gains from the number of under-five lives saved in the first year are above US$28.5 million. The estimates are significantly higher when using lower discount rates. However, given the methodological limitations discussed, using conservative estimates helps attenuate the upward bias.

31. In terms of cost-effectiveness, these estimates of direct gains from economic activity for the short- and medium/long-terms show benefit-cost ratios for malaria case management that support the project on an economic ground. For example, for every US$1 invested, there is a nearly five-fold return accounting for only the short-term effects over the 4-year project horizon. This return increases to US$8.2 when life-time economic gains are considered, using the most conservative discount factor, and not taking into account any other economic gain.

Subcomponent 1.2: Community- and facility -based nutrition services for pregnant women and young children (US$3.0s million)

32. The disease-specific mortality rates for under-five children in Togo put neonatal death, malaria, and diarrhea as the top three causes of under- five mortality in 2008 (WHO/CHERG 2010; UNICEF 2012). Undernutrition underlies disease-specific mortality. Globally, 45% of under five deaths are attributable to undernutrition57 (Liu et al. 2012). In Togo, addressing the stagnation of final nutrition outcomes is important, not only to increase the likelihood of attaining the nutrition MDG targets, but also since reducing undernutrition would have a positive (i.e. a multiplier) effect on improving disease-specific health outcomes.

33. In 2008, the Lancet Series on Maternal and Child Undernutrition provided ample evidence on the effectiveness and cost-effectiveness of interventions that address undernutrition and micronutrient deficiency in women and children. In an updated meta-analysis, based on results from 34 countries that account for 90% of the world’s children with stunted growth, Bhutta at al. (2013) provide evidence of intervention-specific effectiveness and examine the effect of various delivery platforms.

55 The 53 years calculation is derived from WHO’s Life Expectancy table, assuming that the average age at death for under-fives is 3 and LE for both sexes is 56. 56 For GDP growth rate, we assumed 5 percent for the project horizon and, thereafter, 3%, in line with the average for Togo, i.e. between 1995 and 2018 (WEO 2013). 57 Undernutrition encompasses fetal growth restriction, stunting, wasting, deficiencies of vitamin A and zinc, and suboptimal breastfeeding (Bhutta et al 2013).

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34. This subcomponent includes a number of activities that have been proven to be effective and cost-effective, including, for example, growth monitoring (ANC or community-based), promotion of improved IYCF, and provision of IFA supplements for pregnant women, as part of the routine ANC visit.

For example, a quasi-experimental evaluation of a community-based integrated child care

program (C-IMCI) in Honduras (WB 2005), which achieved near universal coverage proved to increase child rearing, feeding and health related knowledge and behavior of mothers. A companion study by Fiedler, Villalobos, and Matos (2008), which focused on the costs of AIN-C, used an activity-based costing approach to calculate annual recurrent costs per child, annual recurrent cost per child, and compared the relative costs of facility-based versus community-based growth monitoring and counseling to inform resource allocation decisions. The study found that the effect of mothers substituting AIN-C monitoring for the traditional facility-based alternative saves 203,000 outpatient visits annually, the estimated monetary value of which is US$1.6 million.

A review of community-based packages (Lassi, Haider, and Bhutta 2010) of care shows that these interventions can result in a doubling of the rate of initiation of breastfeeding in one hour and can also improve other vital MCH process indicators, such as the rate of facility-based delivery (28%). Although further quantitative evidence from large-scale programs is desirable, process indicators and assessments suggest that community health workers are able to implement MCH interventions at scale and, hence, are able to improve child health and nutrition outcomes among difficult-to-reach populations (GHWA 2010). With respect to poverty reduction, by reaching vulnerable and hard-to-reach populations, community-based platforms have proven to reduce inequities in health, including childhood pneumonia, diarrhea, and malaria (Bhutta et al. 2013b; Mukanga et al 2012). Using data from the DHS for Pakistan, Bangladesh, and Ethiopia and stratifying by wealth quintiles, Bhutta et al (2013) provide evidence of the pro-poor nature of community-based nutrition interventions and conclude that this platform does not only reduce overall burden of childhood mortality, but substantially reduces socio-economic disparities in access and mortality.

The assessment of IMCI, which includes both facility and community-based approaches from a number of low and middle income countries, has shown various benefits in health service quality, mortality reduction, and cost savings (Ahmed, Mitchell, and Hedt 2010). In Tanzania, IMCI was associated with significant improvements in equity differentials for six child health indicators, with the largest improvement noted for stunting in children between 24 and 59 months of age (Schellenberg et al. 2004). Similarly, in Bangladesh IMCI was associated with an increase in exclusive breastfeeding and a faster reduction in the prevalence of stunting in children aged between 24 and 59 months (Arifeen et al. 2009).

A Cochrane review (Pena-Rosas et al. 2012) of iron supplementation to women during pregnancy reported a 70% reduction in anemia at term, a 67% iron deficiency anemia (IDA), and 19% reduction in the incidence of low birth weight.

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Using an ingredient’s based approach for costing nutrition interventions (UN One Health Tool – Futures Institute 2012), and calculating unit costs separately for WHO sub-regions, Bhutta et al. (2013) found that unit costs were higher in Africa due to higher labor costs and extra travel time required for delivery using outreach (associated with lower population density and also lower facility density). Such cost drivers are important to consider when assessing the cost-effectiveness and relative cost-effectiveness of nutrition interventions that can run on standard facility-based or community-based platforms.

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MACRO FISCAL CONTEXT AND HEALTH CARE FINANCING Figure 6.2: Togo Macro-Fiscal Context58

Figure 6.3: Togo Health Financing Context

58 Source: Macro-Fiscal Context and Health Financing Fact Sheet (World Bank Fiscal Health Database 2012)

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Cyclical Patterns in Government Health Expendiures

35. Using standard methods from the empirical macro literature, the descriptive analysis presented here aims to identify trends and isolate the cyclical components of the three central variables of interest (GDP, GGE, and GHE). Isolated cyclical components are used to calculate the cyclical correlations between economic cycle and fiscal responses, and economic cycle and government health expenditures. These correlations are then applied in subsequent analyses, such as comparison of the correlation coefficients over time.

Method

Apply a Linear Filter to Derive a Trend Line: As common practice in business cycle

literature, we apply a linear filter to log in transformed variables of interest to detrend the series. This is necessary since, according to Lucas (1977), the business cycle component of the variable is defined as its deviation from the trend. We apply the Hodrick-Prescott (HP) filter to extract the stationary (cyclical) component and nonstationary (trend) component. Practically, the HP filter decomposes the variable, for example, GDP, into an additive cyclical and trend component.i Extracting the trend component yields a stationary cyclical component, which enables the analysis of the cycle, in our case, the business, fiscal response, and Government health spending cycles and the relationship between these cycle components.

Calculate the Cyclical Component of the Time Series: We calculated the cyclical component of the time series, which is the difference between the observed value and the corresponding value on the filtered trend line. The figures obtained this way describe the cyclical behavior of the variable of interest. For example, in the case of an economic output (GDP), if the calculated cyclical component is positive, it means that the cycle is above the expected trend line; if the calculated cyclical component is negative, it means that the cycle is below the expected trend line (i.e. the boom/bust cycle).

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OUTPUT GAP 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010GDP -0.52 2.86 0.50 0.65 -0.01 -0.80 -1.40 0.06 0.19 -0.24 0.31 0.11 -0.11 -0.04 0.19GGE -0.29 0.09 1.42 0.47 0.72 -0.98 -1.83 -0.89 -0.60 0.99 1.89 0.16 -1.14 0.72 -0.41GHE -0.39 -0.07 1.03 0.85 0.66 -0.71 -3.04 0.14 0.32 0.65 1.09 -0.39 -0.65 0.74 -0.23

Figure 6.4: Cyclical component of GDP, GGE, and GHE

Source: Velenyi and Smitz (2013) using Fiscal Health Database (World Bank 2012)

Table 6.3: Output gap for GDP, General Government Expenditures, and Government Health Expenditures

Source: Velenyi and Smitz (2013) using Fiscal Health Database (World Bank 2012) Note: “Output Gap” (OG) measures the difference between the observed value for the variable of interest and the value on the filtered trend for the given year in terms of standard deviation from the trends. Good/bad times are defined as a positive /negative output gap (OG>0/OG<0) relative to the trend line.

Table 6.4: Correlation between cyclical components of GDP, GGE, and GHE (Average, OG<0, OG>0)

Correlation between Cycles Cycle Correlation when

Output Gap < 0 Cycle Correlation when

Output Gap >= 0

Country

GDP_GGE

GDP_GHE

GGE_GHE

GDP_GGE

GDP_GHE

GGE_GHE

GDP_GGE

GDP_GHE

GGE_GHE

Togo 0.37 0.41 0.83 0.55 0.57 0.91 0.05 -0.12 0.73 Source: Velenyi and Smitz (2013) using Fiscal Health Database (World Bank 2012)

36. Calculate Bivariate Contemporaneous Correlations: Drawing on the calculated cyclical components for output (GDP), general Government expenditures (GGE) and Government health expenditures (GHE), we calculated the cross-correlations between the various cyclical components, specifically between the business and fiscal cycles (GDP and GGE), the business and Government health spending cycles (GDP and GHE), and between the fiscal and Government health spending cycles (GGE and GHE). These cross-correlations allow us to establish whether the relationship between business cycles, fiscal responses, and health sector

-0.4

-0.3

-0.2

-0.1

0.0

0.1

0.2

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 GDP CC

GHE CC

GGE CC

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responses are countercyclical or procyclical, that is, whether the cycles move in opposite directions, protecting budgets and health spending during bad times, or in the same direction, signaling increasing expenditure pressures during bad times (see definition for output gap above). A correlation coefficient above zero (+) implies a procyclical relationship. The higher the valueii is between 0 and 1, the more correlated the cycles are. Conversely, a correlation coefficient below zero (-) signals a countercyclical relationship. In this fourth step, we provide a visual overview of cyclical relationships through graphs of overlaid cycles.

37. Definition of Pro/Countercyclical Policy: In the context of economic policy, procyclical (countercyclical) refers to any aspect of economic policy that can magnify (attenuate) economic or financial fluctuations. Countercyclical policies cool the economy when it overheats and stimulate it when there is a downturn. Keynesian economics advocates the use of automatic and discretionary countercyclical polices to lessen the impact of the business cycle.

38. Countercyclical Policy Making – Principles & Practice: Countercyclical Government spending was found to be essential in fostering long-term economic and human development objectives (Brahmbhatt and Canuto 2012; Braun and Di Gresia 2003; Darby and Melitz 2008; Doytch, Hu, and Mendoza 2010).

39. One component of countercyclical fiscal policy is countercyclical social policy, which includes unemployment benefits and other social transfers as well as public expenditures on health and education (Darby and Melitz 2008; Del Granado, Gupta, and Hajdenberg 2013; Doytch, Hu, and Mendoza 2010; Thornton 2008).

40. Because procyclical behavior amplifies economic fluctuations—with adverse effects on Government revenues, poverty levels, long-term growth, and human capital formation (Thornton 2008)—the issue of undertaking social policies as part of the countercyclical response to crises became urgent in the context of the recent global economic slowdown and food price volatility (Doytch, Hu, and Mendoza 2010).

41. Despite these principles, evidence shows that in low- and lower-middle-income countries, protecting public investments in health and maintaining public expenditures on health has not necessarily been the norm (Abbas and Hiemenz 2011; Brahmbhatt and Canuto 2012; Del Granado, Gupta, and Hajdenberg 2013; Doytch, Hu, and Mendoza 2010; Lewis and Verhoeven 2010). Although Lewis and Verhoeven (2010) conclude that countercyclical spending has taken root and countries are (temporarily) expanding safety nets, this improvement is not uniform within regions or income groups; hence, there is still room for improvement. i The methodology consists of adjusting a tendency to the evolution of the logarithm of the variable y (for example, GDP, health expenditures). The difference between the logarithm of the observed value and the estimated tendency (g) yields the cyclical component (c). The objective is to minimize the variance of y around g (subject to the restrictions of penalization of the second difference of g). The penalization parameter λ controls the form of tendency. With higher λ, the tendency will be smoother and result in more recurrent variations. While Braun and Di Gresia (2003) use λ = 100 as the smoothing parameter, in a method overview presentation Baum (2006) proposes λ = 6.25, based on a technical paper by Ravn and Uhlig (2002). Calculating the difference between the original value

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of the variable’s logarithm and the logarithmic tendency estimated by the HP Filter, the cyclical component is obtained. ii The standard threshold values for correlation coefficients are (a) Weak positive (negative) linear relationship via a shaky linear rule, values between 0 and 0.3 (0 and -0.3); (b) Moderate positive (negative) linear relationship via a fuzzy-firm linear rule, values between 0.3 and 0.7 (0.3 and -0.7); and (c) Strong positive (negative) linear relationship via a firm linear rule, values between 0.7 and 1.0 (-0.7 and -1.0).

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Annex 7: Additional Background Analysis

TOGO: Maternal and Child Health and Nutrition Services Support Project COUNTY AND HEALTH SECTOR CONTEXTS Country context and demography 1. The Republic of Togo is a small West African country (surface area: 56,785 Km2) sandwiched between Ghana and Benin, and also bounded by Burkina Faso to the north and the Gulf of Guinea to the south. Its principal towns are Lomé (the capital, with 750,000 inhabitants), Sokodé (50,000 inhabitants), Kara (30,000 inhabitants) and Kpalimé (30,000 inhabitants).1

Figure7.1: Map of Togo

2. The country is subdivided from North to South into five geographical and administrative regions (Savanes, Kara, Centrale, Plateaux and Maritime). It is also divided into two major climatic zones: the savannah North which is mostly infertile and poorer, and the more

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fertile southern zone which contains both a humid greenbelt with two rainy seasons annually, and a less rainy coastal belt that is nevertheless the wealthiest part of the country, as the centres of commerce, industry, fishing and political administration are situated there (principally in Lomé). 3. The heat and humidity that characterize the climate of the country provide a favourable environment for all manner of disease-carrying vectors, such as flies, mosquitoes, rodents, cockroaches, etc. These conditions, combined with inadequate public hygiene, are considered to lie at the root of the country’s epidemiological profile, especially the endemic nature of certain infectious and parasite-borne illnesses, such as malaria and diarrhoea. 4. The total population of Togo was estimated at 5,753,324 people in 2010, and growing at 2.4% per year. The population density is relatively high, at over 100 people per square kilometer, but this is not evenly distributed, with much higher densities in the urban centers of the South, such as the Commune of Lomé which has over 8,300 inhabitants per square kilometer. The population pyramid reflects the typical characteristics of a low income developing country, with a large base (over 43% of the population are aged below 15 years) and a very slim upper part (only 5% of the population are 65 or older).1

Economy 5. The Republic of Togo counts among the least developed countries in Africa with per capita revenue of just US$440 in 2009. Togo is rich in minerals (especially phosphates) and has significant potential in agriculture as well, but despite these resources, the country remains a very low income country. Both commercial and subsistence agriculture are significant in the economy, providing employment for a large section of the labor force. The most important export crops are cocoa, coffee, and cotton, which together generate about 40% of export earnings, with cotton being the most important export cash crop. Phosphates constitute the major mineral export, and Togo is in fact counted among the world's largest producers of this mineral. The Government is keen to develop its reserves of carbon phosphates. 6. Despite recent improvements in political stability and economic reforms, Togo’s growth has remained low, below the regional average, and poverty has remained high. GDP growth showed a modest acceleration from 3% in 2009 to 4% in 2010 and to 5% in 2011 despite a difficult international economic environment. Economic growth rates higher than population growth rate in 2010 and 2011 are encouraging signs of economic recovery; however, these growth figures still remain well below the regional average. While the incidence of poverty improved slightly from 62% to 59% between 2006 and 2011, the situation is still worse than the 32% figures seen in the 1980s. Poverty remains highly concentrated in rural areas where the poverty headcount is above 74%, compared to 23% in Lomé and 45% in other urban areas. In 2011, the country was ranked 162 out of 187 countries (UNDP Human Development Index). 7. With the encouragement of the World Bank and the IMF, the Government has been implementing economic reform measures to boost foreign investment and bring revenues in line with expenditures. Some items on the Government’s reform agenda include privatization of some state enterprises, increased transparency in financial operations, and continued progress

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regarding democratization. Despite its efforts, foreign direct investment inflows have not shown an appreciable increase in recent years, partly due to the continuing uncertainty about socio-political stability, but also due to the implementation of other measures required to improve the investment climate. 8. Table 7.1 gives some major indicators of the macro economic performance in recent years. This shows that real GDP, in particular, has been growing positively but slowly in recent years.

Table 7.1: Some key macroeconomic indicators Economic indicator Value Year GDP (purchasing power parity) note: data are in 2012 US dollars

$6.899 billion 2012 est. $6.569 billion 2011 est. $6.264 billion 2010 est.

GDP (official exchange rate) $3.624 billion 2012 est. GDP - real growth rate 5% 2012 est.

4.9% 2011 est. 4% 2010 est.

GDP - per capita (PPP) note: data are in 2012 US dollars

$1,100 2012 est. $1,100 2011 est. $1,000 2010 est.

Source: index mundi, http://www.indexmundi.com/togo/economy_profile.html, accessed on April 27, 2013. Organization of the health sector 9. The Togolese health system as a whole is organized in the form of a pyramid with three levels: the central, intermediary and peripheral levels. The central level comprises the office of the Minister, the General Directorate for Health (DGS) with its five central directorates and their divisions and services as well as key national level health institutions. The intermediary level is made up of six regional directorates of Health (DRS); and the peripheral level is composed of the district health units, making up the operational and front line facilities. The district health units are administered by 40 separate district directorates of health (DDS). 10. An organizational audit of the MOH undertaken in 2009 revealed that the current set up was inadequate and ineffective for the delivery of its various functions, in particular to be able to attain the MDGs. Based on the analysis of these weaknesses, a new organizational chart for the Ministry was developed with support from the French AFD; it redefines missions and aims at reinforcing the Ministry’s leadership and institutional governance. This has now been adopted by the country’s Cabinet, although roll out (again with AFD, and possible support from other partners) has not yet begun as of this writing. 11. Among the most important changes suggested under the new organizational chart, the Ministry would now have one general secretariat, under which there would be three general directorates: a directorate general for research and planning (with three directorates of research, planning and HMIS); a directorate general for health services (with five services directorates,

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namely for the management of health institutions, hygiene and sanitation, public health and disease control, MCH, and pharmaceutical services); and a directorate general for resources (with three separate central level directorates for HRH, finance and budget, and infrastructure, equipment and maintenance. The permanent secretariat of the regions will also be included under this directorate general of the MOH. 12. In terms of the organizational structure for service delivery, there are also three levels:

The primary health care level is made up of the primary health care units around the district health system with two sub-levels: the lowest sub-level of PHC comprises peripheral health care units (unités de soins périphérique, or USPs), private health care facilities in the communities, and maternity homes). The second primary sub-level in the district health care system is the first reference level facilities (public and private), which may be equipped with surgical units or sometimes without;

The secondary health care level is made up of Regional Hospitals (CHR) and specialized reference hospitals in regions;

The tertiary level comprises teaching hospitals (CHU) and national level specialized hospitals or institutions.

13. A survey of the country’s needs in emergency obstetrical and neo-natal care (SONU), including a mapping of such services undertaken in the country in 2012 showed that Togo has 864 health facilities in all, including 3 teaching hospitals or CHU (2 of them in Lomé, and the third in the North), and 6 regional hospitals or CHR (one in each health region). There are 583 public health facilities, 181 private for profit ones, 37 run by NGOs and associations, 55 missions and religious facilities and eight community-run facilities. 14. It may also be noted that Togo has six health regions, in contrast to its five geographical and administrative regions mentioned above. The sixth region is made up by the Commune of Lomé which has been carved out of the Maritime region for health administration purposes.

MAIN FINDINGS OF THE COUNTRY HEALTH STATUS REPORT

15. In 2011, a country health status report (CSR) looked at the general health situation in Togo, and noted in general that health indicators as a whole had not much progressed in 10 years. In collaboration with the MoH, the World Bank undertook a CSR in 2011 as part of the re-engagement of the Bank in Togo in the health sector after nearly 15 years. The report examined various factors underlying the health performance of the country with an emphasis on the maternal and child health situation as well as on the health system aspects. That CSR forms part of the context for the design of this new health project. Therefore, it is worth summarizing the principal conclusions and findings of that report here, and, in particular, those are of direct relevance for the new project.

Maternal and child health and nutrition context and issues

16. Infant mortality: while the figure of 123 per 1000 in 2010 has decreased since around 1990, the progress has slowed down in more recent years, and even stagnated as of

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2006 (see Table 1 in the main text). These results are explained by a strong prevalence and persistence of malaria among infants in Togo, due in part to difficulties in geographical and financial access to ACTs in certain regions. Less than 15% of kids with a fever receive ACT-based treatment. The CSR also points out the inadequate involvement of community volunteers in malaria care, a situation that could be improved by reinforcing the community health system. 17. However, in terms of prevention activities, great efforts were made to acquire and distribute impregnated mosquito nets (LLINs) and to sensitize the population on their benefits, especially among the population groups most at risk, such as the poor living in rural areas. However, it is considered that the rates of possession and utilization of such nets (at 57% among young children in 2010) remains too low and insufficient to show a real impact on the malaria prevalence. Moreover, according to the CSR, analyses of the MICS 3 and 4 have shown that Togolese households are well informed about bednets and have no hesitation about using them. This suggests that the availability (or rather lack) of bednets is the main obstacle to their wider use. It also tends to justify the importance placed by the GoT on prevention as the most important strategy within its malaria policies, hence also higher resource allocations to this effort. 18. The CSR also contends that, in ten years, Togo has made no real progress in infant malnutrition, although the data examined and presented in Table 1 in the main text do not wholly seem to bear this out, with the exception of chronic malnutrition, which rose from 2006 to 2010. The report does correctly point out that nearly one in three Togolese children still suffers from stunting, and that a strong national policy on malnutrition, based on a multi-sectoral and community approach, remains to be elaborated.

19. Moreover, problems on both the demand and supply side have severely limited accessibility to proper treatment for some common childhood illnesses: on the demand side, financial barriers limit access to diarrhea and pneumonia treatments, while on the supply side, limited availability constrains access to Oral Rehydration Salts (ORS), even in the region with the highest concentration of health facilities (Lomé). 20. Although maternal mortality dropped significantly between 2005 (510) and 2008 (350), Togo is still well behind its MDG target of 160 by 2015. The principal high impact interventions required to reduce maternal mortality in Togo are identified by the CSR as: (i) assisted delivery by qualified medical staff; (ii) regular ante-natal visits during pregnancy; and (iii) effective access to cesarean operations in times of need. Only the last kind of intervention has seen progress in recent times, going from 2% to 5% of deliveries between 2002 and 2009. In contrast, the first two have seen stagnation between 2006 and 2010, which might help to explain the slowing of progress seen in maternal mortality in recent years. 21. The rate of assisted deliveries was 60% in 2010, slightly lower than the 2006 figure of 62%. This slowing of the progress may be explained by supply weaknesses (especially insufficient personnel in rural areas) and financial access issues due to the high costs of these services. Moreover, the quality of maternal care is generally considered to be low, as shown by insufficient drugs and equipment and high fatality rates in maternity units.

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22. Finally, the high fertility rate in Togo, at four children per woman, contributes to the maternal mortality problem, as more adolescents tend to become pregnant (with attendant likelihood of risky pregnancies) and often have to seek abortions in mostly deplorable and unsafe environments. Family planning is also noted as having decreased; with the rate of utilization of all contraceptive methods combined lower now than 20 years ago, a situation that is likely contributing to the high fertility rate and perhaps also slow progress in maternal mortality reduction as well. 23. The CSR also noted that the 3.3% HIV prevalence rate in Togo is well above the West-African average of 1.3%. Consequently, it is an important health priority that the Government is also trying to tackle. In particular, the high prevalence among pregnant women is of great concern, and the Government policy here (with support from the GFATM and other partners) puts emphasis on reinforcing the measures for prevention of mother to child (PMTC) transmission as well as for sensitization work among sex workers. 24. Vaccination strategies appear to be reasonably successful, with an overall coverage of slightly over 80%, but are donor-dependent. The vaccination program has performed increasingly well in recent times, but this program is almost entirely dependent on donors, especially GAVI financing, which is not sustainable. Thus, more efforts are required to increase domestic financing for this program.

Health system issues

25. Governance and leadership of the health system are marked by excessive centralization: Despite an official policy of decentralization, the Togolese health system remains highly centralized. Resources continue to be concentrated at the central (MoH) and regional (Regional Health Directorate) levels, though there are gradual efforts to decentralize towards the district health management team (DHMT) levels. 26. The health governance problem above is made worse by the absence of any real bottom-up process of health planning, and inadequate coordination between the central level and the lower ones. 27. The dysfunctional character of the health management information system (HMIS) is also noted. The HMIS is in fact composed of multiple sub-systems dispersed among different directorates and lacks qualified personnel for the collection and analysis of data. A lack of data verification systems also undermines the quality of whatever data is collected. 28. According to the CSR, the National Health Strategy places emphasis on improving maternal and child health as well as on reinforcing the institutional framework, yet other priorities (such as improving financial access) are not given much attention. The results chain between the objectives and health outcomes desired is also not clear. These weaknesses limit the bargaining power of the MoH when it seeks more resources from the Ministry of Finance and its partners.

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29. Human Resources for Health (HRH) in Togo are clearly insufficient, as in many other low income countries, especially for doctors, specialists and midwives. About 40% of newly qualified doctors migrate abroad every year. The CSR traces the problem to the lack of adequate capacity to produce medical personnel (training institutes) generally, rather than to the rate of migration. Midwives are particularly lacking in rural and remote areas of the country. The few personnel available are highly inequitably distributed over the territory, with 75% of all doctors working in the capital, Lomé. Apart from the concentration of medical training schools in the capital, the country also lacks effective policies or incentives to encourage the personnel to move to rural and remote postings. There is also no results-based system that might encourage a better performance of the existing personnel. Objectives of National Health Policy and Strategies 30. The Togolese Government’s health policy and principal strategies are outlined in the 2012-2015 National Health Plan (PNDS). The PNDS was elaborated, based on the conclusions and recommendations of a situational analysis of the health sector which was supported by all principal partners of the Ministry of Health as well as the earlier National Health Policy framework document drawn up in 2011. 31. It was also elaborated within the context of the Government’s General Policy Declaration which declared the 2010-2015 period as one of accelerated development to achieve an equitable and inclusive growth, with a particular reference to satisfying the needs of the poor and vulnerable, as described in the Togolese PRSP II (DRSP II) document for the period 2012 – 2016. 32. The five main health priorities and objectives of the health sector defined in the PNDS for the 2012-2015 period are: Reduction of maternal and new-born mortality as well as reinforcing family planning; Reduction of child (under five years) mortality; Fight against major diseases – HIV/AIDS, malaria, TB and other diseases, including

non-communicable diseases or NCDs1 (diabetes, hypertension, sickle cell, mental disease, cancer, obesity, mouth and dental diseases, chronic respiratory diseases, etc.), and also potentially epidemic illnesses and neglected tropical diseases;

Promotion of health within an environment favorable to good health; Improvement of the organization, management and delivery of health services.

33. These five priorities were translated into four action programs (the first four in the list above) and a program of support (the fifth on the list), namely reinforcing the national health system and the community health system. The PNDS also defines the expected results, strategies and priority intervention areas for each of these programs. The summary of the 2011 CSR above also describes the principal strategies adopted by the GoT for addressing the priorities related to MCH and HSS which are the focus intervention areas of the new health project.

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TECHNICAL ANNEX ON MALARIA 34. The general objectives of the National Malaria Control Strategy (NMCS) are: (i) to reduce deaths attributable to malaria to near zero by 2015; and (ii) to reduce malaria cases by 75% by 2015 compared to 2000. The approach to malaria control outlined in the NMCS is consistent with international guidelines and best practices. 35. Malaria in Pregnancy There are two key interventions for the prevention of malaria and the consequences of malaria parasitemia in pregnancy: intermittent preventive treatment (IPTp) with at least two treatment doses of an effective antimalarial during pregnancy, and the distribution and promotion of LLIN to pregnant women, which is also a strategy for maintaining LLIN coverage and usage levels between large scale campaigns. 36. Community-Based Diagnosis and Treatment of Malaria The 2011-2016 NMCS calls for parasitological confirmation of malaria infection prior to treatment at all levels. The use of RDTs in community-based management of suspected malaria cases could result in: a reduction of misdiagnosis of malaria by 3.5 million cases and savings of more than US$4.5 million in ACTs over the course of the project (2014-2016). 37. Malaria Treatment costs, cost effectiveness, drug and insecticide resistance, and efficiency of malaria control a. Costs of treatment and diagnosis: The average cost of a full course of malaria treatment using

an artemesinin-based combination treatment (ACT) is US$1.30. The cost of a rapid diagnostic test is approximately US$0.64. Evidence from Togo suggests that only about 58% of fevers seen by community workers are due to malaria; however, all fever instances are treated as malaria under the clinical diagnostic algorithm in use. The scale up of RDTs in community management over three years will cost about US$4.2million and is expected to reduce unnecessary malaria treatments by 2.75million, saving approximately US$3.6million in ACT. This will also reduce drug pressure in the community and result in better outcomes for non-malaria fevers. The total cost of providing LLINs to pregnant women through ANC over three years is approximately US$3.2 million, and the cost of IPTp is only US$340,000.

b. Cost-effectiveness of malaria control: Interventions to prevent and cure malaria have been shown to be very cost-effective with high benefit-cost ratios in a number of studies as well as in the Copenhagen Consensus 2004 (US$2-24 per disability adjusted life year). A recent analysis of sub-Saharan Africa shows a package of malaria preventive interventions to be the most cost effective intervention after childhood immunization.

Drug and Insecticide Resistance: Resistance to both drugs and insecticides are medium- to long-term concerns in malaria control. At present, there is little evidence of resistance to ACTs in Africa, although it is emerging in parts of Asia. Resistance of vectors to pyrethroid insecticides that are used in LLINs has been documented in West-Africa; however, it is still unclear what level of resistance will reduce the efficacy of the interventions. Both of these risks will be monitored through sub-regional efforts supported by the RBM partnership.

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Table 7.2 Funding gap analysis for Malaria in Togo

ESTIMATES (US$) 2014 2015 2016 2017 Total Financial Gap for LLIN in ANC (routine)

$276,693 $301,425 $1,389,496 $1,518,267 $3,485,880

Financial Gap for SP in ANC (IPTp) $43,301 $64,436 $242,730 $275,008 $625,475

Financial Gap for RDTs (communauté)

$115,517 $147,444 $765,969 $818,019 $1,846,949

TOTAL $435,510 $513,305 $2,398,194 $2,611,294 $5,958,304

38. The estimates cover the period 2014-2017 and take into account all GFR9-2 financed commodities. They are based on a methodology and assumptions agreed upon with the NMCP. They take into account commodities to be financed by the Global Fund in 2014 and 2015 (these were largely omitted from the original estimates). Assumptions with respect to program coverage and utilization as well as care seeking behaviors are generally more conservative than in the original estimates. The analysis also incorporates adjustments for annual population growth, the anticipated effects of free service delivery (under the new Government policies) and increased social mobilization for service utilization on demand over the course of the project. TECHNICAL ANNEX ON NUTRITION

Table 7.3: Nutrition technical data

2012 Data from Ministry Plateaux Centrale Total of 2 regions

Total population 1,484,250

672,023 2,156,273

Number of villages 1,897

Number of PIUs 135

80 215

PIUs with CREN 53

47 100

PIUs without CREN 82

33 115

Number of CHWs 2,945

1,902 4,847

Number of pregnant women 48,387

21,908 70,295

Number of children under 5 (estimated from MICS)

224,122

101,475 325,597

Number of children under 2 (estimated from (MICS)

91,442

41,402 132,844

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Projections for 2014

Total population 1,509,881

670,164 2,180,045

Pregnant women 49,222

21,847 71,069

Children under 5 301,976

134,033 436,009

Children under 2 120,791

53,613 174,404

Projections for 2015

Total population 1,547,024

686,650 2,233,675

Pregnant women 50,433

22,385 72,818

Children under 5 309,405

137,330 446,735

Children under 2 123,762

54,932 178,694

Projections for 2016

Total population 1,585,081

703,542 2,288,623

Pregnant women 51,674

22,935 74,609

Children under 5 317,016

140,708 457,725

Children under 2 126,806

56,283 183,090

Projections for 2017

Total population 1,624,074

720,849 2,344,923

Pregnant women 52,945

23,500 76,444

Children under 5 324,815

144,170 468,985

Children under 2 129,926

57,668 187,594

Total pregnant women (all years)

204,274

90,667 294,941

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Table 7.4: Partner Mapping in Togo

Multilateral partners Objectives Attribution / content summary

WHO (World Health Organization)

Leader and coordinator in global health: -policies and strategies - Norms and Standards -Technical-support - Monitoring and programming

Strengthening Health Systems Promotion for equitable access to essential care, fight against diseases, Reproductive Health, etc.

UNICEF (United Nations Children's Fund)

1. Survival and development of young children 2. Child Protection 3. HIV / AIDS and children 4. Basic education and gender equality 5. Analysis of Policy and Partnerships

Immunization, Malaria, Guinea worm, maternal health, newborn and infant juvenile, water component, environment and sanitation, infant feeding, fight against micronutrient deficiencies and malnutrition, health of young people and adolescents, HIV/AIDS, advocacy and partnerships for children's rights

UNAIDS (Joint United Nations Programme on HIV / AIDS)

Universal access to HIV/AIDS prevention, treatment, care and support access

HIV/AIDS /STI: support to NGOs, the NAC, the mobilization of resources (Global Fund, Abidjan- Lagos Corridor Project)

UNDP (United Nations Development Programme)

Strategic support to development problems

Technical and financial support to find solutions to the challenges of democratic governance, poverty reduction, crisis prevention and recovery, environment and energy, HIV / AIDS

UNFPA (United Nations Fund for Population Activities)

1 Poverty Reduction 2. Right to health 3. Gender Equality

Reproductive health, STI /HIV/AIDS

French Development Agency (AFD)

Development of health sector Operationalization of health districts in the Plateaux region - Blood Safety - Capacity building of the Ministry of Health (training, HR, pharmaceutical sector, management) Construction and rehabilitation

European Union (EU) Decentralized support to the health sector

Construction, rehabilitation, equipment, drugs, training, recycling, action research, coaching, information, education, technical assistance, evaluation, audits, support to health NGOs, partnership with the sector

German Technical Cooperation (GTZ / KfW)

Operationalization of health districts, development of basic health care, research and innovation, Support to the Health System Development

- Primary Health Care in Central - Region Urban Health Care in

Commune of Lomé

Chinese Medical Cooperation Chinese Medical Mission Intervention in 2 hospitals (Lomé-Commune and Kara - Tomde)

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USAID Development and poverty reduction

Funding and grants funds for economic and democratic support

GAVI-ALLIANCE

Improve access to immunization Funding program on immunization (EPI) Strengthening the health system

Global Fund against AIDS, Tuberculosis and Malaria

Funding programs to fight against AIDS, Tuberculosis and Malaria

fight against HIV/AIDS, malaria and tuberculosis

Peace Corps Technical and material support to communities

Support communities and individuals in the areas of education, HIV/AIDS, environment and entrepreneurship.

PSI Social marketing in health Social marketing of contraceptives, nets, oral rehydration salts against diarrhea and micronutrients

PLAN TOGO Multiform support Support to the Central and Plateaux Regions

Rotary International Multiform support Cold chain Materials for EPI logistics equipment, organization of National Immunization Days, disaster management, etc.

BID Improving health offers Construction and equipment of health facilities in rural areas (Plateaux, Centrale, Kara and Savanes regions)

DAHW (German Aid Association)

Fight against Leprosy, Tuberculosis

-Funding of research project, training and education for health -Fund programs to fight against leprosy and tuberculosis

International Federation of the Red Cross

Community Health Support to the community health activities and the prevention and management of disasters

Handicap International Support a network of local actors involved in handicap domain

-capacity building of the departments of orthopedics, physiotherapy and speech therapy at the National Medical Auxiliaries School -prevention of Buruli ulcer; -Education, promotion and advocacy for the rights of persons with handicap

AIMES-AFRIQUE Contribute to improving the living conditions of populations Promote the development

Provide quality care to the most needy Improve the conditions of health life Education and training of communities

Borne Fonden Underprivileged children Water, agriculture and livestock, etc. ...

Adventist Development and Relief Agency (ADRA)

Community Development Education and training for rural communities on health, hygiene, sanitation, HIV / AIDS etc.

Sight savers Fight against river blindness and cataract

- Prevention with the control program of aerial spraying -Treatment with drug distribution

Terre des Hommes Protection of children - Fight against the exploitation and trafficking of children - Specialized medical care

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CREPA (Regional Centre for Drinking Water Sanitation and low cost)

Promote sustainable access to safe drinking water, basic sanitation services and behavior change in hygiene for vulnerable people

-Capacity building and human resource development -Action Research Community-management of water projects, sanitation and hygiene -Communication

CBM (Programme against blindness)

Technical and material support to communities

National Programme for the Fight against blindness

National NGOs Attribution / content summary Attribution / content summary

UONGTO (Union of Non-Governmental Organizations of TOGO)

Coordination and strengthening of capacities of NGOs members

Mobilization of financial resources, advocacy and lobbying, communication, monitoring and evaluation

FONGTO (Federation of NGOs in Togo)

Platform for dialogue and exchange between NGOs and various development partners

Coordination, information facilitation, capacity building and support.

OCDI (Charity Organization for Integral Development)

Rural and urban development Health, agriculture, environment, health, cash flow, etc.

ATD (Togolese Diabetes Association)

Fight against diabetes Advocacy, counseling and services, promotion and education

ATBEF (Togolese Association for Family Well-Being)

family Planning Improve maternal and child health

Reproductive Health Sexual Health Services (clinical): Youth, HIV/AIDS Advocacy

RAS + TOGO (Network of Associations of People Living with HIV/AIDS)

Fight against HIV / AIDS Support to social marketing of condoms, advocacy for support of PLWHA awareness and training of target group

FETAPH (Togolese Federation of Associations of Handicap People)

Grouping associations for handicaps

Advocacy, coordination of promotional activities for people with handicaps

Young Men's Christian Association (YMCA)

Rural and urban development Integrated development, sanitation, maternal and child health and building rehabilitation: health houses, latrines

Source: Analyse de la situation du secteur de la santé au Togo

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Table 7.5: Project intervention areas, alignment with to national priorities, other donors involved and gaps identified

Project intervention area identified and agreed with GoT

and partners

National priorities of PNDS 2012-2015 targeted1

Other donors involved, gaps identified for WB project, and other remarks

I. Malaria control (i) Reduction in maternal and neo-natal mortality

(ii) Reduction in child mortality

(iii) The fight against major diseases

• Project to complement the Global Fund’s financing by filling gaps till 2015

• Provide funding from 2015 for (i) routine interventions to support malaria control in pregnancy (ii) community-based diagnosis and treatment of malaria; and (iii) management and supervision, as well as behavioral changes

• No other donor so far providing significant support for these areas beyond 2015 when GF financing ends

II. Chronic malnutrition

(i) Reduction in maternal and neo-natal mortality

(ii) Reduction in child mortality

(iv) Promotion of health within an environment favorable to good health

• Address worsening chronic malnutrition in two most needy regions (Centrale and Plateaux regions) not targeted by the current UNICEF support

• Project will focus on the prevention of chronic undernutrition during the first 1,000 day window of opportunity

• Includes improved infant and young child feeding practices (IYCN), management of childhood illnesses, and safe water, hygiene, and sanitation practices

III. Strengthen the M&E system and support project management and implementation

(v) Improve the organization, management, and delivery of health services.

• No donor currently supporting M&E system

• AFD supporting HRH (central level and midwives), supply chain improvement, etc

• Project to reinforce GoT capacity to monitor its programs

• Emphasis on HMIS as tool to improve the quality of decision making

• Ensure effective project management and implementation