Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized PROJECT INFORMATION DOCUMENT (PID) APPRAISAL STAGE Report No.: AB4517 Project Name Municipal Health Service Strengthening Project (MHSS) 1 Region AFRICA Sector Health (100%) Project ID P111840 Borrower(s) GOVERNMENT OF ANGOLA Implementing Agency Ministry of Health Environment Category B Date PID Prepared April 23, 2009 Estimated Date of Appraisal Authorization May 15, 2009 Estimated Date of Board Approval September 30, 2009 Key development issues and rationale for Bank involvement 1. At 260 deaths per 1,000 live births, the child mortality rate is the second worst in the world after Sierra Leone (270). As shown on the chart, if the present trend continues, Angola has little chance of reaching that Millennium Development Goal (MDG). Maternal mortality, estimated at 1,750 per 100,000, is also among the highest in the world. Figure 1:Trends in under-5 mortality rate 2. The war severely damaged the country s infrastructure, leaving its public administration network and social fabric in tatters. Angola has the highest concentration of landmines globally with 6-7 million mines over 35 percent of the country. The ruined infrastructure, broken public and social network, and the presence of landmines make public service delivery difficult. The war resulted in 65 percent of health facilities being destroyed, while many health staff took refuge in Luanda with an estimated 70% of doctors and 30% of nurses were estimated to be living in 2004. However, during the last 2-3 years the situation completely turned around. According to the results of a survey conducted on health facilities that provide obstetric and neonatal care, 70% of doctors now work at provincial level 2. 3. Even though the government is currently rehabilitating the health network, a high percentage of facilities are still not functional, especially the bottom tier of the health 1 The name was changed at the request of the government. The former name was Health Service Delivery Project (HSDP) 2 Situação do Atendimento Obstétrico em Angola, UNICEF (Situation of Obstetric Care in Angola).
network (health centers and health posts) that is the least functional, and yet this is the main vehicle to deliver primary health care to the population. Angola has only 8 doctors per 100,000 people, much lower than the average for African countries. The result is that 60 percent of the population does not have reasonable access to health care. People still have to walk more than one hour to reach a health facility. 4. Child mortality is mainly caused by malaria, acute diarrheal diseases, acute respiratory infections, measles and neonatal tetanus, which account for 60 percent of child deaths. These can be easily prevented or treated at the primary health care level, and through healthy practices and care at the household level. Child malnutrition, the main associated cause of child mortality, is alarmingly high. UNICEF estimates that 45 percent of children are underweight. This makes children vulnerable to diseases and health problems, and can have enormous social and economic implications in the future. There are an estimated 6 million malaria cases per year, i.e. more than one-third of the population of 18 million is affected. Malaria represents the first cause of mortality (of which 40 percent of perinatal 3 and 25 percent of maternal mortality), illness, and absence from work and school. It has a direct effect of increasing poverty. 5. Maternal mortality. The main causes of death for pregnant women are malaria, hemorrhage, eclampsia, abortion complications, and prolonged labor. Only 25 percent of births are assisted by skilled staff. Complications occur in 15 percent of all pregnancies. Many of the causes of mortality are directly associated to poverty: lack of information at the household level about pregnancy complications and the risk of maternal death, delays in seeking care, lack of rapid access to transport, and insufficient reproductive health services. Yet, with emergency obstetric care in health facilities, skilled staff, proper surgical equipment, a safe blood supply and sufficient drugs, maternal mortality can be greatly reduced. 6. Angola has a great opportunity to make a difference in health outcomes. First, since 2002, the country has been enjoying peace for the first time in more than 40 years. Second, Angola s economic outlook is promising, although it is being affected by the current economic crisis. Angola s economy has been growing strongly at close to 20 percent per annum over the last three years, but GDP is expected to decrease by 4 percent in real terms in 2009 because of OPEC production cuts and the drop in the price of oil. Economic growth is expected to resume in 2010. Third, the problems causing high child and maternal mortality are solvable. In fact, never before has there been as much knowledge in the world about the efficacy and effectiveness of health interventions, as well as the technologies to tackle these health problems. If the country can use this knowledge and spend money efficiently on the right interventions, the health status of the Angolan population can be improved in a relatively short time. 7. The main donors in the health sector are the European Union (EU), the Global Fund, the U.S. President s Malaria Initiative (PMI), and the Bank, which together provide 3 Deaths occurring during late pregnancy (at 22 completed weeks gestation and over), during childbirth and up to seven completed days of life 2
about of US$75-80 million annually. This represents about 14 percent of total public health expenditures. China has also been financing the rehabilitation of health facilities. 8. The government recognizes the important role of the health sector in economic growth. The budget for the health sector significantly increased over the last five years, and even doubled between 2005 and 2006. In 2006, the health budget was US$71 per capita, representing 3.4 percent of GDP. This spending, although high by Sub-Saharan standards, is not having the expected impact on health outcomes, principally because of the low coverage, the poor targeting and quality of services 4, and too much reliance on the provision of health services through fixed-based facilities, i.e. hospitals, health centers, and health posts. With donors support, the government has made commendable efforts to control the HIV/AIDS epidemic and has been successful so far, with prevalence remaining at 2.5 percent. It is also scaling up its malaria control efforts, notably through the distribution of bed nets in all provinces and the replacement of chloroquine, to which the malaria parasites have developed resistance, by artemisin-based combination therapy (ACT). This will contribute to child and maternal mortality reduction. 9. Support of the government health strategy. The government health strategy is presented in a number of key documents: (i) The Government Program 2009-2012 (with a section on health); (ii) the Health Sector Development Plan (currently being updated); (iii) the Revival of Municipal Health Services Plan 5 ; and (iv) the Plan for the Accelerated Reduction of Maternal and Child Mortality in Angola. 10. To improve the health status of the population, especially maternal and child health, the Ministry of Health (MOH) has started to introduce an integrated model of health service delivery consisting of: (i) health facilities providing a complete package of basic health care services; (ii) outreach teams that will start from health facilities and visit municipalities according to a regular schedule, bringing preventive and simple curative services to the population, and (iii) community health workers, supervised by outreach teams, who will mobilize communities, promote healthy behavior in the population, help recognize early signs of illness, and encourage the population to seek care from mobile outreach teams of health facilities when possible. 11. This approach is at the heart of the government s Revitalização Program. This program aims to cover 79 percent of the total population, i.e. about 14.8 million 6. It will cover 80 municipalities (out of a total 147) selected in function of seven criteria: (i) population; (ii) health status: (iii) accessibility, including low risk of mines; (iv) availability of infrastructure; (v) inclusion in the decentralization program of the Ministry of Territorial Administration (to the extent possible); (vi) availability of staff, drugs, and supplies; and (vii) presence of UNICEF and WHO. The Revitalização program will improve the supply and quality of health services, increase access, and thus equity. It will 4 A detailed analysis of health sector issues and the financing of the sector is available in the report Angola Public Expenditure in the Health Sector by the European Union (EU) and the World Bank (2007). 5 Revitalização dos Serviços Municipais de Saúde 6 Based on a population estimate of 18,685,639, used by the DNSP of the MOH 3
improve the planning of health services at the municipal level in function of the needs of the population, provide adequate resources for staffing, equipment, and drugs; and strengthen the management of health services. 12. In 2006, the MOH started to implement the Revitalização program in five provinces: Huila, Bié, Cunene, Luanda, and Moxico. The five provinces and 16 municipalities have prepared health maps, operational plans, budgets, and received training in the use of these instruments. The training experience went well and similar training will be provided in the provinces supported by the project. The MOH has started to develop a Health Management Information System (HMIS), but results are limited. Much more work needs to be done to develop the instruments and train staff in recording the data and using it for decision-making;. The MOH has also started to develop a community health workers (CHWs) program: 1671 community health workers were trained in Huila and 948 in Luanda. This experience has allowed the government to determine that CHWs should be contracted by municipalities and not by the MOH because eventually their functions will be broadened to also cover other sectors such as agriculture, nutrition, and sanitation. The outreach program has been initiated: 130 outreach teams were created and provided with 117 motorcycles and 17 vehicles, and their routes of visits were planned. 13. To expand the geographic coverage of the MHSS to the provinces of Bengo, Malange, Lunda Norte, Moxico, and Uige, the government has asked for support from the World Bank, the Agence Française pour le Développement (AFD), and the Total oil company. The population of the selected municipalities in these five provinces is 1.9 million. Because of difficulties of access that cannot be solved in the near term, the project will effectively cover a population of 1.5 million. 14. The five provinces were selected in close collaboration with the government, based on the seven Revitalização criteria mentioned earlier. Key health indicators for these provinces, presented in Table 1 below, show that they generally fare worse than the Angolan average. Also, in terms of total spending per province, these five provinces are in the lower 50 percent of all provinces 7. This shows that these provinces will benefit tremendously from this project. Table 1: Key health indicators for the MHSS provinces Bengo Malanje Lunda Moxico Uige Angola Norte % prevalence of fever 61.1 55.9 42.3 25.1 38.8 40.0 % prevalence of diarrhea 35.3 33.7 32.4 19.5 26.3 26.2 % prevalence of ARI 8 18.3 4.8 1.7 4.8 3.9 7.0 % exclusive breastfeeding 16.2 17.0 14.9 10.4 37.0 63.9 % women receiving ANC 9 80.1 67.7 67.7 71.4 67.7 79.8 % assisted deliveries 36.4 33.5 33.5 35.0 33.5 47.3 7 EU and World Bank, Angola Public Expenditure in the Health Sector (September 5, 2008) 8 ARI = Acute Respiratory Infection 9 ANC Ante-Natal Care 4
15. The overall framework for local governance in Angola has accelerated rapidly since 2007, especially with the Local Administration Law of January 2007 which: (i) clarifies the responsibilities for services delivered at provincial, municipal and communal levels; (ii) allows for municipalities to become independent budget units; and (iii) gives municipalities a direct connection with the center, through the Ministry of Finance and the Ministry of Territorial Administration (Ministerio de Administração Territorial, MAT). In August 2007, the Cabinet approved the Plano de Melhoria da Gestão Municipal (Plan to Improve Municipal Management), later transformed into the Fund to Support Municipal Management (Fundo de Apoio a Gestão Municipal, FUGEM). The latter s aim is to address many of the financial, human resource and infrastructure challenges that municipal administrations are facing. It identified 68 pilot municipalities that were to receive US$5 million in fiscal transfers for investment during 2008. 16. The MHSS will benefit from Angola s ongoing municipal decentralization program. In the case of the health sector, municipalities become responsible for the management and planning of health services in coordination with other social sectors. They also have more resources that allow them to complement provinces spending in staffing and essential drugs and supplies. Relevance to CAS Objectives 17. The project is directly in line with the Bank s Interim Strategy Note (ISN) for 2007-2009, whose second pillar is supporting the rebuilding of critical infrastructure and the improvement of service delivery for poverty reduction. Project objective(s). 18. The development objective of the project is to improve the population s access to and quality of maternal and child health care services. Preliminary description 19. The project has three components: (i) improving service delivery in the five provinces of Bengo, Malange, Lunda Norte, Moxico, and Uige in 18 municipalities (US$72.8million); (ii) piloting of demand-side incentives to encourage institutional deliveries (US$0.8 million); and (iii) strengthening the capacity of the MOH and municipalities (US$18.2 million). It will have a life of five years. 20. Component 1 - Improvement in service delivery (US$72.8 million). This includes: (i) (ii) (iii) Strengthening of municipal health services at the primary level through training and provision of drugs and supplies; Scaling up of population-based outreached services; Improving community interventions through training; 5
(iv) Improving obstetric care through rehabilitation and construction of delivery rooms in health centers and posts, construction of houses for health professionals at provincial and municipal levels, goods and equipment for pre-natal care, family planning, and delivery rooms, and delivery kits; and improving hospital waste management disposal. 21. Component 2 Piloting of demand-side incentives to encourage institutional deliveries (US$0.8 million). This component will pilot vouchers to encourage pregnant women to deliver in a health facility. These consist of: (i) transport voucher subsidies; and (ii) direct subsidies for pregnant women. 22. Component 3 Strengthening the Capacity of the Ministry of Health at the Central, Provincial, and Municipal Levels (US$18.2 million). This component will have three subcomponents: (i) strengthening program management; (ii) strengthening the capacity of the Department of Planning of the MOH; and (iii) strengthening of monitoring and evaluation. Institutional and implementation arrangements. 23. Institutional arrangements are presented in Figure 2. The National Department of Public Health (DNSP) of the MOH will have the overall responsibility for the management of the project. In 2006, the DNSP created the MHSS Central Coordinating Unit (CCU). The CCU is headed by a Coordinator who reports to the National Director of Public Health, and will be strengthened by the addition of a Deputy Coordinator, an M&E Specialist, an Infrastructure Specialist, a Training Specialist, a Financial Management Specialist, and a Procurement Specialist, as well as supporting staff. This staff will largely come from the existing HAMSET PCU who will become available when HAMSET closes on June 30, 2010, but will start doing a transition to the MHSS as from September 2009, when the MHSS is expected to become effective. Given that HAMSET will not have closed when the MHSS becomes effective, the CCU will recruit a procurement officer and a financial officer who will work under the supervision of the international procurement and financial management specialists. It will also recruit a health specialist. 24. A Project Implementation Unit (the CCU) is justified because the Bank s Interim Strategy Note for The Republic of Angola dated April 26, 2007 explicitly states that to reduce the risk of poor governance to Bank projects, the Bank will take a ring-fenced approach until capacity in government for sound fiduciary management can be built. 25. At the provincial level, Provincial Health Directors are responsible for the implementation of the MHSS. Their role is to coordinate program implementation in the municipalities that are part of the province. To strengthen implementation capacity in each of the five provinces, the project will contract a technical support team of two persons: (i) a public health systems specialist; and (ii) an M&E Specialist. 6
Figure 2: MHSS Institutional Arrangements Ministry of Health National Department of Public Health MHSS Central Coordinating Unit (CCU) Coordinator Deputy Coordinator M&E Specialist Training Specialist Infrastructure Specialist Financial Management Specialist Procurement Specialist Regional Coordinators Provincial Departments of Health Bengo, Malange, Lunda Norte, Moxico, and Uige Municipal Health Officers 26. At the municipal level, the Municipal Health Officer s tasks are to: (i) prepare the MHSS municipal operational plan; (ii) manage the municipal health teams; (iii) prepare a monthly plan of visits to health units to monitor progress and provide implementation support to health staff and mobile teams; and (iv) produce a monthly report documenting the maternal and child health services provided in the municipality. 27. Training will be undertaken by teams of trainers from Luanda and Lubango who will train trainers in Provincial Institutes. While there is a large number of persons to be trained, this is feasible because: (i) there are training institutes in each of the provinces and the overall training workload will be divided into five; (ii) trainers from Luanda and Lubango will train the trainers in each of the institutes; (iii) training materials and curriculums are available; and (iv) there are clear responsibilities in the CCU with a Training Specialist who will manage and coordinate the training program. 28. The Infrastructure Specialist of the CCU will be responsible for civil works and equipment. TORs for the contracting of consultants will be the responsibility of the 7
Deputy Coordinator. The pilot testing of vouchers will be contracted to an NGO. Monitoring and Evaluation will be the responsibility of the M&E Specialist, with access and quality surveys contracted out. Project alternatives 29. Why not HAMSET II? Through HAMSET, the Bank has been the first external financier to help the government control HIV/AIDS, TB, and malaria. This has led the way to further funding from the Global Fund and the U.S. President s Malaria Initiative, and increased financing for HIV/AIDS control from the government itself. On the other hand, maternal and child health indicators are appalling, justifying the strategic decision to give priority to investing in the improvement of these health outcomes. 30. No project alternative. The no project alternative is not desirable because child and maternal mortality are very high in Angola, and malaria devastating. Without an operation that supports an integrated service delivery model, Angola s chances of reaching the MDGs in 2015 would be slim. 31. Lending instrument. In this case, a Sector Investment Loan (SIL) will be used. The SIL is a flexible lending instrument appropriate for a broad range of projects. SILs help ensure the technical, financial, economic, environmental, and institutional viability of a specific investment. They can also support policy reform. Safeguard policies that might apply 32. The project has been classified as B for environmental screening purposes. An assessment of current health care waste management and disposal systems was undertaken. 33. When the HAMSET project was appraised in 2004, practices in health care waste handling, storage and disposal raised environmental and social concerns. There were no national environmental and social policies and regulations for the safe handling, storage and disposal of health care waste. A thorough assessment was conducted, and under HAMSET, the government developed a national Health Care Waste Management Plan. HAMSET helped the government start implementing the plan, including capacity building, mitigation measures and their timely monitoring. Financing for priority actions of the Plan, up to US$200,000 were included in the HAMSET project. 34. At present, there are no available national environmental and social policies and regulations that speak to the safe handling, storage and disposal of health care waste. A sound policy and regulatory environment needs to be put in place so that the government can have the means and capacity to enforce safeguard policies and regulations pertaining to health care waste, and monitor mitigation measures. 35. The MHSS project adheres to the key objectives and activities of the National Health Care Waste Management Strategy. The project will apply the lessons learned from the implementation of the HCWM Plan during the HAMSET project to foster a sound 8
management of health care waste at the national level. The project will emphasize the implementation of this action plan in the five targeted provinces. 36. This project will build on the progress already achieved under HAMSET to help the government improve healthcare waste disposal in the project area and throughout the country. The HCWM Plan was updated in March 2009, and revised to reflect the current realities faced in the targeted provinces. It will be applied through the life of the MHSS project. It involves intensive training and capacity building activities, review of legal and institutional framework, the provision of protective clothing and biosafety kits, basic equipment, technical support, and monitoring. Financing of US$995,000 for activities of the HCWM Plan is included under Subcomponent 3. This is over four times the budget allocated under HAMSET. 37. More progress is required in health care waste management in Angola. Despite the inadequate picture of current health care waste management practices and context, there is reasonably fertile ground for success for the health care waste management plan. The commitment of the central, provincial and local government to the National Health Care Waste Management strategy is encouraging. A new centralized incineration center for infectious health care waste has been established. The government is also contracting three new private waste management service providers to complement the activities of the existing provider, URBANA 2000, and broaden the coverage of the waste management and disposal activities in a safe and timely fashion. Finally, a number of NGOs have been playing a crucial role in public awareness and in behavior change activities targeted at medical staff, cleaning personnel and the general public. 38. The project will build houses for medical staff in 18 municipalities. They will be built on Government land designated for such purpose. The land acquisition and resettlement assessment will be documented, and the project team will verify that no resettlement will occur. Tentative financing Total Project Cost (US$m.): 91.8 Government 16.5 Cofinanciers 35.3 IDA (US$m.): 40.0 Contact point Contact: Jean J. De St Antoine Title: Lead Operations Officer Tel: (202) 473-1898 Fax: (202) 473-8299 Email: Jdestantoine@worldbank.org 9