FOR OFFICIAL USE ONLY RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING THE LIBERIA HEALTH SYSTEMS STRENGTHENING PROJECT CREDIT AND GRANT

Transcription

1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Document of The World Bank FOR OFFICIAL USE ONLY RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF THE LIBERIA HEALTH SYSTEMS STRENGTHENING PROJECT CREDIT AND GRANT BOARD APPROVAL: MAY 30, 2013 TO THE REPUBLIC OF LIBERIA AUGUST 4, 2014 Health, Nutrition and Population- Global Practice Africa Region Report No: RES15904 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

2 ABBREVIATIONS AND ACRONYMS CDC CS CRW EVD FHCI GDS GoL HRITF HSSP IP ISDS ISR MSF MoHSW MWMP NCS NGOs OP PBF PDO TRG UN UNICEF UNFPA WAHO WHO Center for Disease Control Consulting Services Crisis Response Window Ebola Viral Disease Free Health Care Initiative Goods Government of Liberia Health Results Innovation Trust Fund Health Systems Strengthening Project Implementation Progress Integrated Safeguards Data Sheet Implementation Status Report Médecins Sans Frontières Ministry of Health and Social Welfare Medical Waste Management Plan Non-consultative services International Non-Governmental Organizations Operational Costs Performance-based Financing Project Development Objective Training United Nations United Nations Children s Fund United Nations Population Fund West Africa Health Organization World Health Organization Regional Vice President: Country Director: Practice Manager/Manager: Task Team Leader: Makhtar Diop Yusupha B Crookes Trina Haque Rianna Mohammed-Roberts 2

3 LIBERIA Health Systems Strengthening Project CONTENTS A Summary of Proposed Changes 5 B Project Status 6 C Proposed Changes 6 (i) Change in Project Development Objectives 6 (ii) Change in Results Framework 6 (iii) Other Changes to Safeguards 7 (iv) Change in Disbursement Arrangements 7 (v) Reallocations 7 (vi) Change in Disbursement Estimates 8 (vii) Change to Components and Cost 8 (viii) Change in Institutional Arrangements 9 (ix) Change in Procurement 9 (x) Appraisal Summary Change in Economic and Financial Analysis 9 (xi) Appraisal Summary Change in Social Analysis 10 (xii) Appraisal Summary Change in Risk Assessment 10 Annex 1: Results Framework and Monitoring 12 Annex 2: Organization Risk Assessment Framework 16 3

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5 DATA SHEET Liberia Liberia Health Systems Strengthening (P128909) AFRICA Report No: RES15904 Basic Information Project ID: P Lending Instrument: Specific Investment Loan Regional Vice President: Makhtar Diop Original EA Category: Partial Assessment (B) Country Director: Yusupha B Crookes Current EA Category: Partial Assessment (B) Senior Global Practice Director: Practice Manager/Manager: Team Leader: Timothy Grant Evans Original Approval Date: 30-May-2013 Trina S Haque Current Closing Date: 30-May-2018 Rianna L Mohammed- Robert Borrower: Responsible Agency: Ministry Of Finance Ministry of Health and Social Welfare Restructuring Type Form Type: Full Restructuring Paper Decision Authority: Board Approval Restructuring Level: Level 1 Financing ( as of 25-Jul-2013 ) Key Dates Project Ln/Cr/TF Status Approval Date Signing Date Effectiveness Date Original Closing Date Revised Closing Date P IDA Effective 30-May Jul June May May-2018 Disbursements (in Millions) Project Ln/Cr/TF Status Currency Original Revised Cancelle d Disburse d Undisbur sed P IDA Effective XDR % Disburse d Policy Waivers Does the project depart from the CAS in content or in other significant Yes [ ] No [ X ] 4

6 respects? Does the project require any policy waiver(s)? Yes [ ] No [ X ] A Summary of Proposed Changes Level 1 restructuring of the Liberia Health Systems Strengthening Project (HSSP) (P128909) is needed to address the emergency Ebola outbreak in Liberia, which is evidenced by an increasing number of people infected with the Ebola Viral Disease (EVD) This restructuring is part of an overall Bank emergency response to the ongoing EVD crisis It will support efforts underway by the Government of Liberia (GoL), and its partners, to contain and control the outbreak Approval of the Board is sought for this restructuring which will introduce a number of changes to the HSSP and amendments to the Project's legal documents The restructuring would entail a revision of the Project Development Objective (PDO) in order to expand the scope of the Project to include emergency health services for the general population, in support the GoL s efforts to contain and control the Ebola outbreak It would also: (a) include a new component ("Support to the Emergency Response to the Ebola Epidemic"), which directly supports the emergency response needed to contain and control the Ebola outbreak; (b) reallocate US$6 million to the new component (Component 4) (US$4 million from Component 1 and US$2 million from Component 2); (c) revise the implementation arrangements by amending the procurement plan to allow for potential contracting of UN agencies and international organizations/ Non-Governmental Organizations (NGOs) to deliver emergency services to the population, and by changing the disbursement arrangements to allow for the use of UN Advance procedures under the new component; and (d) revise the Results Framework to reflect the changes in the scope of the Project Change in Implementing Agency Yes [ ] No [ X ] Change in Project's Development Objectives Yes [ X ] No [ ] Change in Results Framework Yes [ X ] No [ ] Change in Safeguard Policies Triggered Yes [ ] No [ X ] Change of EA category Yes [ ] No [ X ] Other Changes to Safeguards Yes [ X ] No [ ] Change in Legal Covenants Yes [ ] No [ X ] Change in Loan Closing Date(s) Yes [ ] No [ X ] Cancellations Proposed Yes [ ] No [ X ] Change to Financing Plan Yes [ ] No [ X ] Change in Disbursement Arrangements Yes [ X ] No [ ] Reallocation between Disbursement Categories Yes [ X ] No [ ] Change in Disbursement Estimates Yes [ X ] No [ ] Change to Components and Cost Yes [ X ] No [ ] Change in Institutional Arrangements Yes [ X ] No [ ] Change in Financial Management Yes [ ] No [ X ] Change in Procurement Yes [ X ] No [ ] Change in Implementation Schedule Yes [ ] No [ X ] Other Change(s) Yes [ ] No [ X ] Appraisal Summary Change in Economic and Financial Analysis Yes [ X ] No [ ] 5

7 Appraisal Summary Change in Technical Analysis Yes [ ] No [ X ] Appraisal Summary Change in Social Analysis Yes [ X ] No [ ] Appraisal Summary Change in Environmental Analysis Yes [ ] No [ X ] Appraisal Summary Change in Risk Assessment Yes [ X ] No [ ] B Project Status The Project is a US$10 million Investment Project Financing (IPF) funded through an IDA Credit, with co-financing of US$5 million from the Multi-donor Trust Fund for Health Result Innovation (HRITF) The project was approved on May 30, 2013 and became effective on June 16, 2014 The PDO is to improve the quality of maternal health, child health, and infectious disease services in selected secondary-level health facilities The Project has the following three components: Component 1- Strengthening the Institutional Capacity to Improve the Quality of Selected Health Interventions at PBF Health Facilities ; and Component 2- Improving health worker competencies to address key health-related concerns at selected health facilities, and Component 3- Project Management Despite the delay in project effectiveness, a number of key activities- which are funded by an additional (project preparation) HRITF grant- are ongoing/ completed, thereby enabling implementation to be fast-tracked/ accelerated As such, progress towards achievement of the PDO was rated moderately satisfactory in the last Implementation Status Report (ISR) Implementation progress, however, was rated moderately unsatisfactory due largely to the significant delay in project effectiveness One consequence of this delay in effectiveness has been a lack of disbursement thus far The Project will request additional financing in the amount of US$6 million in order to replace reallocated funds, to ensure full implementation of Components 1 and 2, and achievement of the PDO C Proposed Changes Project Development Objectives Original PDO Development Objectives/Results The PDO is to improve the quality of maternal health, child health, and infectious disease services in selected secondary-level health facilities (i) Explanation Change in Project's Development Objectives The PDO is being revised in order to expand the scope of the Project to include emergency health services for the general population of Liberia, in support of the GoL s efforts to contain and control the Ebola outbreak, as detailed in their "Operational Plan for [an] Accelerated Response to [the] Reoccurrence [of the] Ebola Epidemic" Proposed New PDO The revised PDOs are to: improve the quality of maternal health, child health, and infectious disease services in selected secondary-level health facilities; and to support the emergency response needed to contain and control the Ebola outbreak (ii) Explanation: Change in Results Framework

8 The Results Framework will be revised to reflect the proposed emergency health response, and the expanded scope of the Project to include the general population One new outcome indicator will be added to the results framework, which tracks the number of international doctors and other medical workers who are contracted to: (a) support the Ebola control efforts; and/or (b) provide back- up medical services in facilities where national medical workers have been redeployed to support Ebola case management In addition, the target for output (and IDA core) indicator health personnel receiving training and Direct Project Beneficiaries will be increased to take into account increased training of health workers in Ebola control efforts (including case detection, case management, surveillance and diagnostics) as well as increased service provision to the general population Compliance (iii) Explanation: Other Changes to Safeguards The existing Medical Waste Management Plan (MWMP) will be updated to include an Annex on World Health Organization (WHO) Protocols regarding the handling of Ebola Likewise, the Integrated Safeguards Data Sheet (ISDS) will also be updated Both the updated MWMP and ISDS will be disclosed in-country and at the InfoShop (iv) Explanation: Financing Change in Disbursement Arrangements With the Ebola outbreak, there has been a complete breakdown of the already weak and under-resourced health system in Liberia To support an effective and immediate implementation of emergency activities in-country and recognizing the strong complementarities between United Nations (UN) Agencies (eg World Health Organization (WHO), United Nations Children's Fund (UNICEF), United Nations Population Fund (UNFPA), etc) and other international organizations/ NGOs to provide emergency health services, it is proposed to introduce the possibility of using UN Advance procedures as the disbursement mechanism for the new Component (Component 4) In the event of direct contracting with a UN agency/ international organization/ NGOs, the Government will sign a contract/ convention with the UN agency/ international organization/ NGOs The Bank will create a UN Advance Account and advance the agency directly Once the funds are utilized, the agency will be required to submit a utilization report to the bank, for documentation purposes (v) Explanation: Reallocations The proposed change is a reallocation of US$4 million from Component 1 ("Strengthening the Institutional Capacity to Improve the Quality of Selected Health Interventions at PBF Health Facilities"), and US$2 million from Component 2 ("Improving health worker competencies to address key health-related concerns at selected health facilities ") to a new component- Component 4: "Support to the Emergency Response to the Ebola Epidemic" Reallocated funding will be used to support the emergency response needed to contain and control the Ebola outbreak in Liberia (eg case management, case detection, surveillance and diagnostics) Ln/Cr/TF Currency Current Category of Expenditure Allocation Disbursement % (Type Total) 7

9 IDA Gds, Cons, Train, Opr Costs Part 1A Gds, Cons, Train, Opr Costs Part 1B Gds, Cons, Train, Opr Costs Part 2A Gds, Cons, Train, Opr Costs Part 3 Gds, Cons, Train, Opr Costs Part 4 Current Proposed Current Proposed Total: NA-NA Disbursement Estimates (vi) Explanation: Change in Disbursement Estimates Total: It is expected that the Project will disburse the reallocated US$6 million over a period of months, with approximately 30% disbursed in the next 3-6 months to provide targeted emergency health services This should be additional to expected disbursements under components 1, 2 and 3 although depending on the time and resources required to contain and control the EVD, there may be delays in the implementation of original project activities Fiscal Year Current (USD) Proposed (USD) , ,550, ,000, ,500, ,000, ,500, ,500, ,200, ,000, , ,00000 Total 10,000, ,000,00000 (vii) Explanation: Change to Components and Cost Components A new component- Component 4 ("Support to the Emergency Response to the Ebola Epidemic") will be added, which directly supports the emergency response to the Ebola crisis Specifically, funding under this Component will be used to support the following key activities, which are in line with the Government's emergency response plan developed with the support of partners: (a) Coordination, financing and logistics; (b) Epidemiology, Surveillance and Diagnostics; (c) Case management, Infection prevention, control and psychosocial support; (d) Social Mobilization/ Communication; and (e) Support to the functioning of the 8

10 overall health system in this crisis period Under case management, for example, funding will be provided to support the hiring of international doctors and other medical workers, who will be responsible for: (a) supporting the Ebola control efforts; and/ or (b) providing back- up medical services in facilities where national medical workers have been redeployed to support Ebola-related activities (eg case management and case detection) The latter will also help to support the overall health system Also, one cross-cutting requirement across activities (a) to (e) above will be the need to procure essential equipment and supplies (including preventative and protective equipment) The funding for Component 4 (US$6 million) will be reallocated from Component 1 in the amount of US$4 million and Component 2 in the amount of US$2 million Current Component Name Strengthening the institutional capacity needed to improve the quality of selected health interventions at PBF health facilities Improving health worker competencies to address key health-related concerns at selected health facilities Proposed Component Name Current Cost (US$M) Proposed Cost (US$M) Action Revised Revised Project Management No Change Support to the Emergency Response to the Ebola Epidemic Total: New (viii) Explanation: Change in Institutional Arrangements Other Change(s) In order to support the Government of Liberia (GoL), UN agencies (eg WHO, UNICEF, UNFPA) and international organizations/ NGOs may be contracted on a sole source basis by the Liberia Ministry of Health and Social Welfare (MoHSW) to provide Ebola-related emergency health services to the population In such case, UN agencies and international organizations/ NGOs would be responsible for supporting the provision of services and/or technical assistance under Component 4 to help respond to the severity of the Ebola crisis in Liberia Liberia has put in place an Ebola National Task force (chaired by the President of Liberia), which includes the Country Representative of the WHO, to develop and operationalize a response plan to the crisis At the regional level, WHO is setting up an Ebola response center in Conakry, Guinea involving other international agencies, such as the Center for Disease Control (CDC), Institute Pasteur (France), Médecins Sans Frontières (MSF), UN agencies, and the West Africa Health Organization (WAHO) The Center will serve as the main sub-regional operations hub to strengthen coordination, and optimize the utilization of resources in support of outbreak control and containment activities, across affected countries 9

11 (ix) Explanation: Change in Procurement The original procurement plan applied Quality Based Selection for the contracting of firms However, UN Agencies and/or other international organizations/ngos may need to be contracted on a single-source basis by the Borrower responding to emergency situations, or when these agencies/organizations are uniquely qualified to provide the required TA, advice, and services in their area of expertise When hiring UN agencies, the Borrower will use the Bank s standard form of Agreement between a Borrower and a UN agency for the provision of TA and services agreed by the Bank (x) Explanation: Change(s) in Appraisal Summary Appraisal Summary Change in Economic and Financial Analysis Liberia's medium-term economic prospects are positive, in the absence of any major economic shocks Available data for the first quarter of 2014 point to continued strong growth However, the deepening of the Ebola crisis could precipitate a substantial economic crisis in Liberia with major economic and fiscal implications On the one hand, substantial fiscal resources, even beyond increased donor contributions, may be required for health interventions as well as for social protection interventions while on the other hand, there could be a substantial decline in fiscal revenues from the sharp reduction in economic activity and investment inflows The expansion of the Ebola crisis, for example, is expected to lead to a sharp reduction in both tourist and business travel to Liberia Already, two regional airlines have suspended flights to Liberia The reduction in travel to Liberia will have a sharp adverse economic impact on the fledgling hotel and restaurant sector and will undoubtedly lead to the laying-off of workers and a reduction in the demand for local goods and services (xi) Explanation: Appraisal Summary Change in Social Analysis The EVD, and limited successes at controlling it, is strongly linked to social and behavioural determinants These include extreme fear, as well as cultural practices and traditional beliefs, which result in mistrust, apprehension and resistance to the adoption of recommended public health preventive measures The implication of this include poor health care seeking behavior such as hiding of EVD patients, home-based management of EVD patients, and customary treatment of dead bodies These are very high risk practices leading to extensive exposure to the Ebola virus in the community Also, the extensive movement of people within and across borders has facilitated the rapid spread of the infection across and within the three countries The homogeneous communities living along the border areas have common socio-cultural activities that enhance viral transmission This challenging environment is further compounded by weak health systems, and some general mistrust related to governance and institutional structures (xii) Explanation: Appraisal Summary Change in Risk Assessment The Ebola crisis in the country has elevated the overall risk for the Project from substantial to high Specifically, the deepening Ebola crisis could precipitate a substantial socio-economic crisis in Liberia, with major social, economic and fiscal implications Substantial fiscal resources, even beyond increased donor contributions, for example may be required to return the provision of health interventions to pre- Ebola levels, and to improve the resilience of the health system to the respond to any future epidemics/ outbreaks The crisis, for example, has been responsible for a significant loss of life among health workers, particularly considering the very low levels of health workers in Liberia In addition, there is a deep level of mistrust and fear both among health workers and the general population This may adversely affect 10

12 health-seeking behaviors, and the provision of services Finally, the ability to both rapidly mobilize international health workers, and to facilitate training of health workers at decentralized levels, will be constrained and challenged by the Ebola crisis, coupled with the increasingly weak health system and severely limited capacity As such, and in an effort to mitigate against these risks, the project will provide funding to directly support the emergency Ebola response at both the national and decentralized levels This funding will include support to overall health system strengthening efforts, with an attempt made to contract with international partners/ NGOs who have a comparative advantage - both in terms of capacity and experience- in specific areas related to the control and containment of the epidemic 11

13 Project Name: Team Leader: Product Line: Liberia Health Systems Strengthening (P128909) Rianna L Mohammed-Roberts Requesting Unit: IBRD/IDA ANNEX 1: Results Framework and Monitoring LIBERIA: Health Systems Strengthening Project Responsible Unit: Country: Liberia Approval FY: 2013 Region: AFRICA Project Development Objectives Original Project Development Objective: Lending Instrument: Project Stage: Restructuring Status: DRAFT AFCW1 Created by: Rianna L Mohammed-Roberts on 31-Jul-2014 GHNDR Modified by: Rianna L Mohammed-Roberts on 01-Aug-2014 Specific Investment Loan The Project Development Objective (PDO) is to improve the quality of maternal health, child health, and infectious disease services in selected secondary-level health facilities Proposed Project Development Objective (from Restructuring Paper): The revised PDOs are to: improve the quality of maternal health, child health, and infectious disease services in selected secondary-level health facilities; and to support the emergency response needed to contain and control the Ebola outbreak Results Core sector indicators are considered: Yes Project Development Objective Indicators Results reporting level: Project Level Status Indicator Name Core Unit of Measure Baseline Actual(Current) End Target No Change Health Facility Quality Index at Target PBF Facilities Text Value The baseline value for Target to be set following

14 No Change Maternal and child death audits carried out routinely by target PBF health facilities according to national guidelines Redemption Hospital is 45% Baseline for other facilities should be available in Dec 2014 determination of baseline Date 31-Jul May-2018 Comment Percentage Value Date 03-Jan May-2018 Comment Revised Direct project beneficiaries Number Value Date 03-Jan Aug May-2018 Comment No Change Female beneficiaries Percentage Value New Doctors and other medical workers who are contracted to: (a) support the Ebola control efforts; and/ or (b) provide back- up medical services Sub Type Supplemental Number Value This indicator has been revised to include beneficiaries of Ebola control and containment activities Date 01-Aug Apr-2018 Comment 13

15 Intermediate Results Indicators Status Indicator Name Core Unit of Measure Baseline Actual(Current) End Target No Change No Change No Change No Change No Change No Change Performance contracts negotiated and signed with target facilities, and updated annually based on modifications to the quality checklist Proportion of facilities that received quarterly performance-based payments based on their performance, and as per their contracts Proportion of PBF target facilities with no stock-outs of Essential MNCH Drugs and commodities Proportion of counterverification reports submitted to the MOHSW within two weeks after the end of each 6 month period Targeted PBF facilities that achieve at least 80% of the activities defined in annual business plans In-Service Training programs in Obstetrics, Pediatrics, Number Value Date 18-Jan May-2018 Comment Percentage Value Date 18-Jan May-2018 Comment Text Value Baseline to be collected during the first year of project implementatio n 100% Date 18-Jan May-2018 Comment Percentage Value Date 18-Jan Jan-2018 Comment Percentage Value Date 18-Jan May-2018 Comment Text Value 0 42 Date 18-Jan May

16 No Change Revised Surgery, and internal medicine carried out on a quarterly basis in project target facilities Knowledge score of residents according to key curriculum benchmarks Health personnel receiving training (number) Comment Number Value This corresponds to at least 1 training session per month in each target facility Date 18-Jan May-2018 Comment This baseline exam- which will determine entry into the residency program took place in August 2013 Number Value Date 18-Jan Jan-2018 Comment This indicator is cumulative and has been revised to include: staff trained to support Ebola control and containment activities) 15

17 ANNEX 2: Operational Risk Assessment Framework (ORAF) Liberia: Liberia Health Systems Strengthening (P128909) Project Stakeholder Risks Stakeholder Risk Rating Substantial Risk Description: Unfamiliarity with PBF, and very limited capacity to manage and implement PBF functions at the national, county and health facility levels, coupled with possible slower than expected initial disbursements, may lead to resistance from key stakeholders, in favor of input based financing This may affect the early stages of implementation PBF is not entirely consistent with the funding modalities used by other development partners (DPs) This, and in particular, the financing leverage held by DPs- an estimated 83% of health expenditure in Liberia is externally funded- might lead to some resistance, and discourage the MoHSW from scaling up the PBF approach Developing and supporting a GMRP may be considered at odds with perceived development priorities in Liberia For example, there may be express opposition in favor of support to lower-cost, high impact interventions (eg community-based health workers) - despite a dearth of specialist health workers The residency program involves many different actors, all with very specific roles and responsibilities in the implementation of the residency program Key The Bank and project team will work closely with the MoHSW and stakeholders on the ground to ensure that the PBF approach is explained clearly, and adequate capacity building is programmed, through both intensive PBF training courses, and a long-term TA Significant TA will be made available to the project team, implementing agencies, and health facilities during project implementation as needed Bank In Progress Both Intensive technical discussion and coordination have already taken place with DPs ensure that there is close coordination, and that approaches and tools are harmonized as far as possible In addition, the Bank will actively engage with DPs during project supervision The Bank will also work closely with NGOs and civil society Civil society, for example, will assist will community-level verification of health facility performance Both In Progress Both The team will collaborate and work closely with key stakeholders (international, regional and national organizations) early in the process to ensure buy-in, with an emphasis on highlighting the critical importance of focus specialist areas in achieving health outcomes (including the health-mdgs) Existing disciplines of focus were chosen in very close consultations with the government of Liberia These disciplines are expected to make the greatest impact on development objectives The team will also 16

18 stakeholders, including the medical school, JFK, affiliated training sites, the LMDC and others may reject the specific design of the residency program, affecting the early implementation of the residency program Managing and coordinating Ebola-related activities may prove to be challenging and complex, given the range of stakeholders involved Implementing Agency (IA) Risks (including Fiduciary Risks) emphasize the mechanisms inherent in component II that will see core competencies trickle down from physicians in teaching hospitals to all health cadres in affiliated facilities including those in more hard to reach areas Bank In Progress Both The government has initiated conversations and discussions with a number of key stakeholders, and will convene a meeting during project Appraisal to clearly identify and formalize the respective roles and responsibilities of the different actors in the implementation of the residency program Client Completed Preparation In an effort to ensure coordination, the MOHSW will work closely with all key partners through a National Task Force that has already been established, and is functional The project will facilitate this process by enabling the MOHSW to directly contract with UN agencies/ international organizations/ NGOs based on their comparative advantage Resp: Client Status: Ongoing Capacity Rating Substantial Risk Description: Inadequate financial management capacity at MoHSW could pose the risk that financial management tasks and related fiduciary covenants are not be adequately complied with Procurement proficiency is limited to the Public Procurement and Concession Act of Liberia There is Stage: Implementation Recurrent Due Date Frequency The established and well-functioning Office of Financial Management (OFM) will be responsible for the financial management of the project The Unit is staffed with a capable full-time Controller and project accountants who have the requisite experience on Bank financial management guidelines This will help mitigate the risks resulting from a lack of Coordination Client In Progress Implementation 17

19 limited capacity in donor procurement processes However some of the staff of MOH have recently attended courses in World Bank procurement procedures MoHSW s project unit, as well as the PGMC, and the LMDC may not have sufficient technical knowledge and operational capacity to lead and manage the project s focus on quality of care improvements through PBF and improved health worker competencies Insufficient management capacity, as well as basic infrastructure (eg housing for residents and faculty), and equipment may pose a challenge to the implementation of component II activities An assessment of the procurement capacity of the MoHSW concluded that the Procurement Unit has the requisite staff who are experienced to handle procurement under the project The procurement unit is headed by an experienced and well qualified Director of Procurement He is ably supported by an equally qualified Deputy Procurement Director and a Procurement officer who has had experience in donor funded project and has also attended various courses in World Bank procurement guidelines The procurement risk was assessed as Moderate Both Completed Both Close hands-on technical assistance (TA) will be provided by a TA agency, and by the Bank team, and through dedicated project funds on quality of care improvements, contract management, and PBF (including health facility management) For example, the LMDC will be provided with adequate TA to ensure that they are able to carry out quality and quality verification, and the intensive coaching of health facilities envisioned This will be complimented by training of key stakeholders in PBF Both Not Yet Due Implementation Target health facilities which will serve as teaching and affiliated teaching hospitalswill receive intensive support from the Bank, amply supported by TA as needed A capacity needs assessment will inform the team of gaps in infrastructure and supplies and equipment In addition to funding direct investments for critical equipment and supplies, health facilities will receive up-front PBF grants to assist with infrastructure improvements (eg infrastructure), and can use incentives for further infrastructure and equipment improvements The project has budgeted separately for accommodation costs for both residents and faulty during the residency program Both In Progress Implementation 18

20 Governance Rating Moderate Risk Description: The legacy of weak governance institutions, accountability and enforcement mechanisms as a result of the 14-year civil war pose the risk of weak ownership and accountability for results In an effort to improve services delivered- both the quality and clinical content- patient satisfaction may be deprioritized The Government has made notable progress in building the foundation for improving economic governance, including the strengthening of the General Auditing Commission, improving cash management and controls and establishing the Anti-corruption Commission Implementation arrangements will be monitored and reviewed during semi-annual supervision missions, and also more frequently if needed In addition, there will be a strong focus on results, with both ex-ante and ex-post verification and counterverification Both In Progress Both The continued improvements in financial management and procurement systems and procedures supported by technical assistance from the World Bank, the AFDB, IMF, USAID, Sida, EU and other donors have helped improve the fiduciary control environment to minimize opportunities for fraud and corruption This a key factor in mitigating the fiduciary risks Moreover, through a DFID financed capacity building TA support to MoHSW, OFM has been significantly strengthened and is currently staffed with adequate personnel with the requisite experience and qualifications to carry its functions under the project This will further minimize project fiduciary risks Both In Progress Both Anti-corruption clauses have been incorporated in all bidding documents and RFPs and contracts Bank Completed Preparation 19

21 One cross-cutting issue monitored by the quality checklist is client satisfaction In addition, grievance procedures will be put in place to address any mistreatments/ mishandling between both health workers, and health workers and patients In the case of patients, for example, the Community health leader who sits on the Hospital Health Board-will be the grievance focal point Patients will be able to discuss grievances directly with the community health leader, or by writing these down, and placing in a suggestion box Health facilities will be required to ensure that grievance procedures are understood by, and understandable to illiterate populations All grievances will be discussed at monthly Hospital Board Meetings, with mechanism to address grievances- in the case of deliberate wrongdoing- enforced In addition to this, mechanisms to address grievances among health workers will also be developed (including redress mechanisms) and enforced by health facilities Adherence to these grievance mechanisms will be monitored closely in the quality checklist Client Not Yet Due Both The continued improvements in financial management and procurement systems and procedures supported by technical assistance from the World Bank, the AFDB, IMF, USAID, Sida, EU and other donors have helped improve the fiduciary control environment to minimize opportunities for fraud and corruption This a key factor in mitigating the fiduciary risks Moreover, through a DFID financed capacity building TA support to MoHSW, OFM has been significantly strengthened and is currently staffed with adequate personnel with the requisite experience and qualifications to carry its functions under the project This will further minimize project fiduciary risks Both In Progress Both Anti corruption clauses have been incorporated in all bidding documents and RFPs and contracts 20

22 Project Risks Bank Completed Preparation Design Rating Substantial Risk Description: Some of the risks associated with PBF include: (i) gaming the system by inflating service delivery records or inflating the results of the quality evaluation or establishing too easily achieved management indicators; (ii) favoring service delivery to easier to reach populations; and (iii) focusing on only targeted services to the detriment of other equally important health interventions Setting of incentives for services contains a risk of budget overruns and insufficient levels of incentives to motivate health facilities, and in particular, staff to improve performance Improvement of hospitals can attract more patients from health centers and health clinics, including the patients who should be treated at the primary level Scaling up resident graduate training capacity may not be considered an effective and efficient use of resources Doctors and nurses with graduate medical degrees for example are often prone to outmigration and disproportionate uptake of urban employment Under component II, there is a risk that the program is unable to attract and/or finance an adequate number of suitably qualified faculty for the GMRP Physicians under the GMRP may be reluctant to rotate to The project will address these risks by: (i) incorporating quality measures as an integral part of the process of determining payments to facilities/health workers; (ii) incentivizing utilization of a very limited number of services; (iii) establishing strong verification and counter-verification systems to reduce the risk of manipulation of data; and (iv) involving communities in the verification process, regularly monitoring service delivery to the most disadvantaged, and making the necessary adjustments to service tariffs to favor service delivery in remote areas Both In Progress Both The project will make use of incentive setting tools that allow for incentive adjustments based on budget constraints (top-down budgeting) and reasonable incentive levels (bottom up budgeting) Incentives will be reviewed periodically, and updated as needed In addition, the project will experiment with innovative ways of providing incentives; for example, to departments rather than individual staff members Both Not Yet Due Implementation The MoHSW will ensure that sufficient support from the government and partners will be provided at the primary facilities in project counties In addition, in order to mitigate against distortions in terms of patient flow, the project will focus largely on improving the quality of care, with only limited support to improved utilization of a specific number of under-provided or under-utilized services Both In Progress Both 21

23 health facilities in marginalized areas under the training, and/or to provide envisioned training to lower level health cadres This may jeopardize the envisioned competency building for front line health workers cadres PBF focusing on quality at hospitals in a fragile country is new and innovative, thus may have challenges especially in incentivizing the adherence to clinical processes and verifying results The Bank will work closely with the government and the respective teaching hospital intended to provide graduate resident medical education to develop and implement a core set of interventions to minimize outmigration and disproportionate urban job uptake of students This includes developing admissions policies preferential to uptake of students from rural backgrounds, create rotating residency training in rural teaching facilities, and making rural work experience and placement a core component of the residency program, and developing bonding requirements upon completion of the residency Such interventions are inherent to the project, and have globally shown to significantly reduce outmigration and urban uptake Finally, the partnerships with lower level training institutions, and front line service providers, will ensure that advanced skills trickle down to the front line workers quickly, to address development challenges in a shorter time frame Both In Progress Both Recognizing these challenges, the team will focus primarily on developing suitable incentive packages to attract teaching faculty from the Africa region The team will also work closely with various partners at the international level to identify additional funding sources to fund relevant incentives, as well as identify opportunities for volunteers from abroad, or retirees from Liberia, to form part of the teaching faculty Both In Progress Both The project team will work closely with the Ministry of Health to develop suitable incentive packages for health workers to rotate and provide training to health workers in hard to reach area facilities Such incentives should match the current government top up provision for physicians carrying out rural postings In addition, funding under the project will fund a critical housing allowance, the lack of which is often considered a key barrier to rural uptake of employment posts The team will also carefully assess the types of incentives that will be needed, and develop a mechanism under PBF to incentivize intervention facilities to ensure and monitor the provision of training to all 22

24 health workers Both In Progress Both PBF design of the project including approaches to incentivize the adherence to appropriate clinical processes has been developed with internal and external leading experts in PBF and clinical quality improvement It adopts a five year quality framework to improve the quality (especially clinical processes) year-by-year and avoid overwhelming the hospitals It will use pre-pilot activities in Redemption hospital to test and modify the activities, and use regular steering committee to stock-take the progress and adjust approaches Both In Progress Both Emergency health services are being provided in a difficult situation, and in a weak environment As such, it may be challenging to rapidly mobilize international health workers, and also to facilitate training of health workers at the district level In an effort to mitigate against this risk, the MoHS will contract with international partners/ NGOs who have a comparative advantage in this area Resp: Client Status: Not yet due Social and Environmental Rating Moderate Risk Description: Risks related to handling and disposal of medical and health waste: the proposed project is classified as Category B for environmental screening purposes given the risks associated with the handling and disposal of medical and health waste such as syringes and material used during deliveries Stage: Implementation Recurrent Due Date: Frequency: The existing Environment and Social management Framework (ESMF) and the Health Care Waste Management (HCWM) plan have both been updated and disclosed in country and at the Infoshop The MOHSW and PMU will work closely to monitor implementation of the HCWM plan by health facilities during project implementation The Bank team will also follow up with two times a year supervision missions during the project implementation In addition, a number of target health facilities will have their incinerators rehabilitated There will also be intensive training for all medical and para-medical staff in the project target facilities on HCWM The WHO protocol for 23

25 Ebola will be made available in-country and disclosed at the InfoShop The implementing partners of the project will maintain attention to social and environmental developments that could jeopardize the quality, objectivity, and regional nature of the Program A stakeholder assessment has been carried out to determine potential opposition to the proposed project or certain components of the project, and relevant consultations and negotiations held In addition, key features of the project- and in particular, attention to under-served populations- is expected to result in positive responses Client In Progress Both Program and Donor Rating Substantial Risk Description: Expected complementary support for the development of the Graduate Medical Residency Program (GMRP) from donors and TA agencies does not materialize, or is less than expected During project preparation and implementation, a consultative process will be undertaken with the relevant bilateral and multi-lateral donors, TA entities, and professional associations, which have already shown interest in supporting the GRMP to determine and/or solidify joint or parallel funding, and technical support Both In Progress Both Delivery Monitoring and Sustainability Rating Substantial Risk Description: Quality of care improvements at health facilities may not be sustainable once the project ends Lack of financing for the GMRP in the longer term could jeopardize the continued sustainability of the program The cost of indicators will be kept at sustainable levels throughout project implementation to enable the Government to take over the program in the future By spending about US$15 per capita per year, the cost of the project is likely to be financially sustainable in the medium term The support from the partners including funds from USAID and EU will be harmonized under the MoHSW s leadership, which increases the opportunities for sustaining the PBF through both public sector and other external financing Apart from financial sustainability, significant capacity building and TA will help to ensure technical and institutional sustainability 24

26 Overall Risk Both In Progress Implementation The Bank will introduce cost sharing for the residency program early on, incrementally passing the cost of the program over to the government The team will work closely with the government to develop and implement a strategy to ensure financial sustainability of the GMRP This will include working with the government to develop respective funding modalities and ensuring that interventions are innovative, cost effective and continue to be of benefit even after WB funding ends Both In Progress Both Overall Implementation Risk: Rating High Risk Description: The Ebola crisis in the country has elevated the overall risk for the Project from substantial to high Specifically, the deepening Ebola crisis could precipitate a substantial socio-economic crisis in Liberia, with major social, economic and fiscal implications Substantial fiscal resources, even beyond increased donor contributions, for example may be required to return the provision of health interventions to pre-ebola levels, and to improve the resilience of the health system to the respond to any future epidemics/ outbreaks The EVD, for example, has been responsible for a significant loss of life, particularly among health workers In addition, there is a deep level of mistrust and fear both among health workers and the general population This may adversely affect health-seeking behaviours, and the provision of services Finally, the ability to rapidly mobilize international health workers, and also to facilitate training of health workers at decentralized levels, will be constrained and challenged by the Ebola crisis, and the increasingly weak health system with severely limited capacity As such, and in an effort to mitigate against these risks, the project will provide funding to directly support the emergency Ebola response at both the national and decentralized levels This funding will include support to overall health system strengthening efforts, with an attempt made to contract with international partners/ NGOs who have a comparative advantage - both in terms of capacity and experience- in specific areas related to the control of the epidemic In spite of proposed mitigation measures, a High risk rating is considered appropriate, particularly given the weak and fragile country context 25