Public Disclosure Authorized. Public Disclosure Authorized. Public Disclosure Authorized. Public Disclosure Authorized. Report No.

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1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Project Name Region Sector Project ID Borrower(s) Implementing Agency Environment Category Djibouti-Health Sector Development Project Middle East and North Africa Region Primary Health; Including Reproductive Health; Chi; Hospitals; Secondary & Tertiary; Reform and Financing DJPE71062 GOVERNMENT OF DJIBOUTI Date PID Prepared March 4, 2002 Auth Appr/Negs Date March 14, 2002 Bank Approval Date June 4, 2002 Address MINISTRY OF HEALTH AND SOCIAL AFFAIRS Address: MinistOre de la Sante, P.O. Box 2123, Djibouti-Ville, Republique de Djibouti Contact Person: M. Ali Sillaye Aballah, Directeur, Unite des Gestions des Projets Tel: Fax: B Report No. PID Country and Sector Background The major issues in the health sector are (a) high maternal and child mortality rates; (b) increasing rates of TB, HIV/AIDS and other infectious diseases; (c) malaria which used to non-existent has made a major come-back; (d) vaccination coverage stagnating or declining; (e) shortage of personnel particularly in remote facilities; (f) chronic and sometimes acute shortages of medicines and other consumables in health facilities; (g) poor sector management including capacity to monitor and plan. Despite these poor health outcomes, the Government is spending almost seven percent of GDP. Part of the reason for this high expenditure is the high costs of staff (many foreign) and the high costs of medicines and other inputs. In addition poor system management, reliance on curative care and large periods during which facilities are idle leads to high cost and low impact.the Government proposes to address these problems by: (a) improving the quality of service offered by health facilities in order to attract more patients to the facilities; (b) launching national campaigns against AIDS, TB and other infectious diseases; (c) starting a campaign against malaria; (d) reinvigorating the vaccination campaign; (e) train more paramedics and improve their conditions of service; (f) introduce cost-sharing and community pharmacies complemented by a National Drug Fund to assure a long-term sustainable supply of medicines; (g) restructure sector management including establishing a Directorate for Planning and

2 Information; (h) provide administrative autonomy to major health facilities The Government is quite aware that it needs to focus first on the key elements of improving services such as availability of medicines and better preventive care to keep public support strong for health care reforms. Thus, they are giving high priority addressing the drug supply question and resolving the issue of adequate and qualified personnel in health centers.the Government has already moved ahead on the overall sector management restructuring by passing a new general law for the health sector (what are the main points of this new law?). This law will be progressively implemented through specific decrees which are being prepared. The Ministry of Health has been restructured to create four specialized Directorates and has separated basic care services from tertiary care - the four directorates are: epidemiology, basic care, HIV/AIDS and the Peltier hospital. In addition, a planning Directorate has been created to develop and monitor information systems and provide donor coordination. A Credit Administrative Unit (CAU) has been established to manage disbursement, procurement, financial management for all projects, under the aegis of the Secretary General's office. 2. Objectives The project objective is to improve the quality of basic services through (a) improvement of maternal and child health services; (b) improved availability of para-medical personnel; (c) better availbility of medicines in health facilities; and (d) increased capacity of the Government to implement and execute reforms. 3. Rationale for Bank's Involvement The World Bank's global experience in health sector reform will bring an important element to the project design. The Bank group has supported health sector reforms elsewhere in the region, e.g. Egypt, Jordan, Lebanon, Morocco and Oman. It has also acquired significant sector reform experience in other regions of the Bank. IDA's participation has encouraged the participation of many other donors as evidenced by support during the donors meeting. 4. Description Phase I consists of four components:component A. Improve Health Services: (i) Improve the Physical and Human Capacity of Health Facilities. This sub-component would contribute to rehabilitating the maternity, emergency services and pediatric services at the Peltier hospital. In addition, technical capacity would be strengthened for urban dispensaries to better attract patients who would otherwise go to the Peltier hospital(ii) Safe-motherhood programs. Strengthen the Safe Motherhood Initiative, principally by improving the management of obstetrical complications and emergencies in health facilities that can be managed by both surgical and non-surgical interventions through better training, increased availability of medications, and infrastructure improvements. The project will also reinforce and expand some promising initiatives to better educate the population about women's health issues (through community health workers), mobilize resources to promote positive health outcomes (through non-governmental organizations), and better monitor births being attended by traditional birth attendants in the community.(iii) Integrated Management of Childhood Infections (IMCI) Apply the Djiboutian Safe Motherhood model (sound central management, human capacity building at all levels, and strengthening of selective system supports), and extend the - 2-

3 cross-institutional collaborations that have been developed by the Safe-Motherhood Initiative at all levels (CNFPS, local NGOs, Community Health Workers, mass media, etc.) to advance child health aims. The Project will both support the WHO-endorsed initiative of early implementation of IMCI in 4 urban health facilities (Engueila, Arhiba, Farahad and Ambouli) and extend this support to 4 additional urban health facilities and the 4 district hospitals to achieve national coverage. The standard WHO approach of strengthening health worker skills, improving health system supports, and improving family and community practices that has been followed in other WHO/EMRO and WHO/AFRO countries will be adopted.(iv) Reinforce Malaria Control Efforts. Targeted communicable disease activities intended to improve malaria control and routine immunization services in Djibouti can enhance the efforts of IMCI and Safe-motherhood to improve child and maternal health. In addition to improving the case management of fever and the promotion of bednet use through IMCI, the Project will support complementary efforts by the Division of Hygiene and Epidemiology to reduce malaria-related mortality and morbidity. The Project will support a variety of malaria control strategies, including plans to improve the diagnostic capacity of lab technicians, to promote the adoption of personal protection measures in communities not immediately served by health facilities, to extend selected vector control activities, and to institute sentinel surveillance. (v) Support Immunization Efforts: IMCI's policy of vaccinating every sick child in need will be complemented by efforts to strengthen routine immunization services for well children. Particular emphasis will be given to better training of health personnel, with particular emphasis on improving health workers' interpersonal and patient education skills; organizational improvements to reduce waiting time and improve cold chain management; ensuring routine availability of all antigens; and ensuring completion of the multi-dose series of DPT for all children. Component B: Improve Availability and Quality of Human Resources: This is one of the biggest problems facing Djibouti - the overall shortage of qualified personnel is reinforced by disincentives for them to work because of poor service conditions. (i) Expand Capacity of Centre de Formation pour le Personnel de la Sante (CFPS). The physical capacity of the CFPS will be expanded to produce more paramedics both for the three year course and the two year course. The enhanced capacity will also help CFPS organize continuing education programs in its facilities. In addition, internet access to health information will be made available in the CFPS library for use by all personnel working in the sector.(ii) Short Term Courses. The project will finance short-term courses at the CFPS as needed. The courses which will be made available first is likely to include training for health workers on managing drug supply and helping to set-up community pharmacies, training in IMCI and safe-motherhood. Training courses will be offered as needed bringing in expertise from inside and outside the country. The project will finance external trainers, development of training modules and other direct costs of short-term training.(iii) Improve Service Conditions for Paramedical Workers. A trigger to move from Phase I to Phase II will be improvement in the job conditions offered to fully trained para-medics (those with Diplomes d'etat) bringing them to a similar level as the Instituteurs with civil service status in the Ministry of Education. This will reduce the drop-out rate of trained people from paramedical jobs to other jobs. In addition, to attract qualified paramedics to remoter locations and replace the untrained personnel there, a premium will need to be paid similar to -3 -

4 that for teachers in remote areas. This is also a trigger for moving from Phase I to Phase II.Component C: Improve Drug Supply:(i) Emergency Supply of Medicines and other Medical Consumables. Given the acute shortage of drugs and consumables in health facilities, the project will finance an initial stock of essential drugs for health facilities. The amount and type of drugs will be based on the national list which has been established by type of facility. A pilot program for cost-sharing through community pharmacies will tried along with the emergency stock.(ii) Train MOH Personnel in Drug Stock Management and helping to set up Community Pharmacies. The MOH personnel need training in managing drug supplies and eventually in setting up community pharmacies which would provide low cost generic drugs acquired from the drug fund. The training will be based on existing modules prepared by UNICEF for the Initiative du Bamako and will be offered through CFPS. (iii) Support the Establishment of a Drug Fund (CAMME). The project will finance the setting up of a Centrale d'achats de Medicaments et Materiels Essentiels (CAMME). CAMME will be set up as an NGO recognised officially as a public service organisation (association a but non lucratif reconnue d'utilite publique) and able to receive and manage public funds. CAMME will operate under special arrnagement with the Government which will include an operations manual approved by both sides. CAMME will buy drugs from the cheapest quality sources and sell them to public and non-profit health establishments with a small mark-up to finance its operating costs. A Business Plan been prepared and financial simulations carried out which show that CAMME will be able to become financially sustainable in a reasonable period of time. The public health establishments will sell the drugs through a community pharmacy or directly (in case they are legally autonomous) and the proceeds of the sales will be used to restock. The prices will be agreed by the MOH before hand and prescription protocoles established to assure that there is no tendency to over prescribe to increase revenues. The public budget will also finance drugs and is expected to cover the difference between cost sharing revenues and needs. The difference is expected to be significant as there will be drugs which have public good elements and may need subsidies. The project will finance the initial stock of drugs and technical assistance and training necessary for a drug fund. Physical rehabilitation of facilities and equipment has already been financed by another donor.component D: Improve Sector Management: This will be supported in four ways.(i) Support Administrative Autonomy for Hopital Peltier: Technical assistance and training will be provided to support the autonomy of this hospital. The support provided to improve the facilities under component A will also contribute to making the autonomy viable. (ii) Support the Capacity of new Directorate of Planning, Health Information and Donor Coordination (BEPCI). This will done through the provision of training, international technical assistance, national technical assistance and direct support to carry out surveys. BEPCI will take the lead in monitoring impact and the surveys will be major part of the work. Surveys to be financed during Phase I include PAPFAM (Pan Arab Population and Family Health Survey) as two rounds of quality of service surveys at health facilities. In addition, equipment and other help need to revitalize the health information system will be provided.(iii) Support the Capacity of other Technical Directorates of the Ministry. The new reorganization implies need for training and TA to help the new structure work. (iv) Support Capacity building for Operations and Maintenance. While the instituion of cost sharing will provide resources for better O&M, it will be necessary provide technical capacity so that the - 4 -

5 maintenance may be carried out. The project will support contruction and equiping of a maintenance workshop to be located at Hopital Peltier but with service responsibilities across the country.(iv) Support the Credit Administration Unit (CAU) ): The CAU as part of the Ministry's new structure, reports directly to the Secretary General. Its main role will be carry out the procurement, financial management and reporting needs for donor funded projects, which will be executed by the Technical Directorates. The project will provide the support necessary to the CAU to manage the credit. Improve Health Services Improve Availability and Quality of Trained Personnel; Improve Drug Supply Improve Sector Management 5. Financing Total ( US$m) BORROWER 2 IDA 15 ABU DHABI: ABU DHABI FUND FOR ARAB ECONOMIC DEVELOPMENT 2 AFRICAN DEVELOPMENT BANK 5 ARAB FUND FOR ECONOMIC AND SOCIAL DEVELOPMENT 6 EC: EUROPEAN COMMISSION 1 FRANCE: FRENCH AGENCY FOR DEVELOPMENT 3 ISLAMIC DEVELOPMENT BANK 2 ITALY: DEV. COOP. DEPARTMENT (MOFA) 1 FRANCE: MINISTRY OF FOREIGN AFFAIRS (MOFA) 3 SAUDI ARABIA: SAUDI FUND FOR DEVELOPMENT 5 Total Project Cost Implementation The Ministry of Health will implement the project through its concerned technical directorates. The Directorate of Basic Health Care will execute IMCI and Safe-Motherhood Initiative using existing units already set-up. The Malaria and Immunization programs will be led by the Directorate of Epidemiology while human resource development will be led by the Director of CFPS working closely with technical directors. The Ministry's unit responsible for managing donor funded projects is the Credit Administration Unit (CAU) who will handle procurement, disbursement, financial management and reporting functions. The key personnel for the CAU were appointed in February 2002: a Director, a Financial Management Specialist, and a procurement specialist. An accountant and other support staff will be appointed shortly. The CAU will be responsible for the day-to-day management of the project activities. Its responsibilities will specifically include:* Coordinating with the relevant departments in the MOH and other health facilities to ensure technical aspects are in line with overall ministry strategies, * Handling all relations with IDA on behalf of the MOH, including management of the special account and other project funds, maintaining project accounting records and supporting documents in accordance with acceptable accounting standards, monitoring and evaluation, and submission of progress and quarterly reports, * Preparing all procurement packages (i.e. bidding documents, RFPs, RFQs,...etc.), and participating in all evaluation committees, and* Is there a steering committee?financial Management ArrangementsThe financial management of the project will be carried out by the newly established UGP/CAU in MOH. The structure of the unit will comprise qualified - 5 -

6 financial management personnel: a financial officer and an accountant. The unit will be in charge of keeping accounting records and related documentation, ensuring that all authorization and payments are in accordance with the credit agreement and IDA's requirements. They will produce financial reports as required by IDA, other donors, the Government, and other stakeholders. An external independent auditor acceptable to IDA will be recruited to undertake annual audits of the project accounts prior to credit effectiveness. TORs will be cleared by IDA prior to external auditors appointment. The borrower will open a special account at a commercial bank acceptable to IDA, which will be managed by the UGP/CAU. Credit proceeds will be disbursed based on traditional disbursement methods of SOEs, Special Account replenishment and direct payments. Supporting documentation will be submited to IDA along with the request for withdrawal/replenishment for all expenditures above the thresholds. A training of both financial staff as well as procurement officer will take place prior to credit effectiveness, to ensure that staff understand IDA's financial and procurement management requirements and disbursement procedures and are able to perform their jobs properly. During appraisal, IDA mission agreed with the borrower on the financial management arrangements to be in place before effectiveness to ensure that these comply with IDA's minimum requirements as per OP An action plan was prepared and discussed with the PCU Director and Finance Officer and is currently under implementation. The action plan will be fully implemented before credit effectiveness. The action plan aims mainly at ensuring that: n Qualified staff are recruited and properly trained; n Adequate financial management systems (accounting, internal control, financial and procurement regulations and procedures, and reporting) are in place;n Qualified independent external auditors acceptable to IDA are appointed for the first year of operations; The Director started the recruitment process of the accountant. A management consultant is also planned to be hired to help the CAU staff develop adequate financial management systems and procedures prior to credit effectiveness (see action plan for details). Draft Terms of Reference of the accountant position, the management consultant work assignment, and the annual external audit were discussed with the CAU Director. ProcurementA Country Procurement Assessment (CPA) has not yet been carried out for Djibouti, but the experience with other projects in the country indicate overall weak procurement capacity. Currently, procurement activities in the MOH are handled in the Finance and Administration Department (preparation of bidding documents), while evaluation takes place by a committee nominated by the Procurement Commission. The Procurement Commission is a high tender board in the country that is headed by the Secretary General of the Government. It nominates evaluation committees for all procurement activities above. A Bank-approved standard bidding document for NCB is available and is being used by both the ADETIP and Education projects. The same document will be used by the UGP/CAU. The first phase of the APL involves three types of procurement activities; civil works, goods (including drugs), and consulting services and training. The procurement officer in the CAU will be responsible for preparing bidding documents and RFPs, in collaboration with the technical departments of the Ministry, which will be responsible for developing technical specifications and terms of reference. Technical assistance may also be sought in certain areas to support the technical departments in the Ministry to develop specifications and terms of reference. The architectural drawings and bidding documents for the civil works that will - 6 -

7 take place during the first year of the project (mainly Peltier) are under preparation, using PHRD funds, and will be finalized before project negotiations. Details on the procurement aspects are presented in Annex Sustainability Djibouti spends a significant amount of resources on the health sector with little results to show. The project will support measures to increase the efficiency of resource use, which should in turn help to reduce the rate of increase in Government health expenditures. The project will not build any new structures thus limiting the potential increase in recurrent costs. The introduction of partial cost sharing should not help to improve services but would also reduce the potential for increase in the public budget. The Drug Fund (CAMME) and community pharmacies should also help to reduce future growth of public health expenditures. 8. Lessons learned from past operations in the country/sector This project draws on the World Bank Group's global experience in health sector reform. The first improtant lesson of health reform is that there should be immediate perceptible improvements in service quality to maintain support for the reforms. A second important lesson is to bring all vested interests on board during the planning and design phase. Another lesson is that health reforms cannot take place without reforms in public expenditure management since health is primarily a publicly financed sector. IDA is supporting these general public expenditure management reforms through the PATARE project and through a Fiscal Consolidation Credit. In addition, given past experience, and the way donors have participated in the sector, there has been little sustainability of the sector as a whole thus the project has been prepared in close discussion with all donors culminating in the donors conference held in Djibouti in February, The project will attempt to reinforce training within the country through the strengthening of the national health training center (CFPS), and limit the amount of non-returnees from overseas education programs by promoting training in Francophone Africa (rather than Europe), without overtly sacrificing on the quality of the education. Drug supplies have become donor dependent and sporadic. The project will address this through support for CAMME and for community pharmacies. 9. Program of Targeted Intervention (PTI) N 10. Environment Aspects (including any public consultation) Issues : Following the mission to Djibouti, the EMP has been finalized and has been appropriately disclosed both in country and in the Bank Infoshop. The EMP is particularly focusing on capacity building in order to improve the management of hospital waste and on the promotion of good health care practice in order to decrease the risk of secondary or nosocomial infections and also to promote the use of environmentally friendly ways of protecting the population at risk against malaria vectors. 11. Contact Point: Task Team Leader Qaiser M. Khan The World Bank 7-

8 1818 H Street, NW Washington D.C Telephone: (202) For information on other project related documents contact: The InfoShop The World Bank 1818 H Street, NW Washington, D.C Telephone: (202) Fax: (202) Web: Note: This is information on an evolving project. Certain components may not be necessarily included in the final project. This PID was processed by the InfoShop during the week ending March 15,