FOR OFFICIAL USE ONLY INTERNATIONAL DEVELOPMENT ASSOCIATION PROJECT APPRAISAL DOCUMENT ON A PROPOSED GRANT

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1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Document of The World Bank FOR OFFICIAL USE ONLY INTERNATIONAL DEVELOPMENT ASSOCIATION PROJECT APPRAISAL DOCUMENT ON A PROPOSED GRANT IN THE AMOUNT OF SDR 2.4 MILLION (US$3.68 MILLION EQUIVALENT) AND A GRANT IN THE AMOUNT OF US$5 MILLION Report No: PAD652 FROM THE MULTI-DONOR TRUST FUND FOR HEALTH RESULTS INNOVATION TO THE REPUBLIC OF THE GAMBIA FOR A MATERNAL AND CHILD NUTRITION AND HEALTH RESULTS PROJECT AFTHW Country Department AFCF1 Africa Region February 28, 2014 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. i

2 CURRENCY EQUIVALENTS (Exchange Rate Effective January 31, 2014) Currency Unit = Gambian Dalasi (GMD) GMD 37.5 = US$1 SDR 1 = US$ FISCAL YEAR January 1 December 31 ABBREVIATIONS AND ACRONYMS ANC B/C BFC BFCI CBA CBO CCT CDDP CHN CLTS CPPR CPR CSO DHS FM GAVI GDP GFATM GIFMIS GMD GMP GNI HCWMP HMIS MDTF-HRI IC ICB IDA IEC IFR IPT IQ ISA IT Antenatal Care Benefit/Cost Baby Friendly Community Baby Friendly Community Initiative Cost-Benefit Analysis Community-Based Organization Conditional Cash Transfer Community-Driven Development Project Community Health Nurse Community-Led Total Sanitation Country Portfolio Performance Review Contraceptive Prevalence Rate Civil Society Organization Demographic Health Survey Financial Management Global Alliance for Vaccines and Immunization Gross Domestic Product Global Fund to fight AIDS, Tuberculosis and Malaria Gambian Integrated Financial Management Information System Gambian Dalasi Growth Monitoring and Promotion Gross National Income Health Care Waste Management Plan Health Management Information System Multi-Donor Trust Fund for Health Results Innovation Trust Fund Individual Consultant International Competitive Bidding International Development Association Information Education Communication Interim un-audited Financial Reports Intermittent Preventive Treatment Intelligent Quotient International Standards on Auditing Information Technology ii

3 IVA IYCF LGA LQAS M&E MBB MCNHRP MDFT MDG MICS MMR MOFEA MOHSW MOLGL NaNA NCB NLTA NPV OP ORAF PAD PAGE PBF PDO PHC PIC POM RBF RHT SAM SBCC SBD SDR STI SUN SW TA TFR TOR TT UN U5MR UNFPA UNICEF US$ VAS Independent Verification Agency Infant and Young Child Feeding Local Government Area / Authority Lot Quality Assurance Sampling Monitoring and Evaluation Marginal Budgeting for Bottlenecks Maternal and Child Nutrition and Health Results Project Multi-Disciplinary Facilitation Teams Millennium Development Goals Multiple Indicator Cluster Survey Maternal Mortality Ratio Ministry of Finance and Economic Affairs Ministry of Health and Social Welfare Ministry of Local Government and Lands National Nutrition Agency National Competitive Bidding Non-Lending Technical Assistance Net Present Value Operational Policies Operational Risk Assessment Framework Project Appraisal Document Program for Accelerated Growth and Employment Performance-Based Financing Project Development Objective Primary Health Care Project Implementation Committee Project Operations Manual Results-Based Financing Regional Health Team Severe Acute Malnutrition Social and Behavior Change Communication Standard Bidding Documents Special Drawing Rights Sexually Transmitted Infection Scaling Up Nutrition Staff Week Technical Assistance Total Fertility Rate Terms of Reference Tetanus Toxoid United Nations Under-five Mortality Rate United Nations Population Fund United Nations Children s Fund United States Dollar Vitamin A Supplementation iii

4 VDC VSG WHO YR Village Development Committee Village Support Group World Health Organization Year Regional Vice President: Makhtar Diop Country Director: Vera Songwe Acting Sector Director: Tawhid Nawaz Sector Manager: Trina S. Haque Task Team Leader: Menno Mulder-Sibanda iv

5 THE GAMBIA Maternal and Child Nutrition and Health Results Project TABLE OF CONTENTS Page I. STRATEGIC CONTEXT...1 A. Country Context... 1 B. Sectoral and Institutional Context... 1 C. Higher Level Objectives to which the Project Contributes... 7 II. PROJECT DEVELOPMENT OBJECTIVE...8 A. PDO... 8 B. Project Beneficiaries... 8 C. PDO Level Results Indicators... 8 III. PROJECT DESCRIPTION...8 A. Project Components... 8 B. Project Cost and Financing C. Lessons Learned and Reflected in the Project Design IV. IMPLEMENTATION...14 A. Institutional and Implementation Arrangements B. Results Monitoring and Evaluation C. Sustainability V. KEY RISKS AND MITIGATION MEASURES...19 A. Risk Ratings Summary Table B. Overall Risk Rating Explanation VI. APPRAISAL SUMMARY...19 A. Economic and Financial Analysis B. Technical C. Financial Management D. Procurement E. Social (including Safeguards) F. Environment (including Safeguards) v

6 Annex 1: Results Framework and Monitoring...26 Annex 2: Detailed Project Description...30 Annex 3: Implementation Arrangements...38 Annex 4: Operational Risk Assessment Framework (ORAF)...51 Annex 5: Implementation Support Plan...55 Annex 6: Economic and Financial Analysis...58 Annex 7: Map of The Gambia...69 Tables Table 1: Trend in MDG 1c, 4 and 5 in The Gambia...2 Table 2: Health outcome indicators, 2005/06 and 2010/ Table 3: Health and nutrition outcomes by Local Government Area...3 Table 4: Barriers to utilization and/or adoption of key health services and behaviors...4 Table 5: Summary of activities by component...9 Table 6: Project budget and IDA financing by Component actions...13 Table 7: RBF functions and responsible entities...14 Table 8: Internal and external verification arrangements...16 Table 9: Cost-benefit analysis of The Gambia MCNHR Project...22 Table 10: Estimated child and maternal mortality reduction by Components 2 and vi

7 ..... PAD DATA SHEET The Gambia: Maternal and Child Nutrition and Health Results Project (P143650) PROJECT APPRAISAL DOCUMENT AFRICA AFTHW Report No.: PAD652 Basic Information Project ID EA Category Team Leader P B - Partial Assessment Menno Mulder-Sibanda Lending Instrument Fragile and/or Capacity Constraints [ ] Investment Project Financing Financial Intermediaries [ ] Series of Projects [ ] Project Implementation Start Date Project Implementation End Date 25-Mar Jan-2019 Expected Effectiveness Date Expected Closing Date 30-Jun Jul-2019 Joint IFC No Sector Manager Sector Director Country Director Regional Vice President Trina S. Haque Tawhid Nawaz Vera Songwe Makhtar Diop Borrower: Central Bank of The Gambia Responsible Agency: National Nutrition Agency (NaNA) Contact: Modou C. Phall Title: Executive director Telephone No.: modoucheyassinphall@yahoo.com Project Financing Data(in US$ Million) [ ] Loan [ X ] Grant [ ] Guarantee [ ] Credit [ X ] IDA Grant [ ] Other Total Project Cost: 8.68 Total Bank Financing: 3.68 Financing Gap: 0.00 Financing Source Amount BORROWER/RECIPIENT 0.00 IDA Grant 3.68 Health Results-based Financing 5.00 Total 8.68 vii

8 Expected Disbursements (in US$ Million) Fiscal Year Annual Cumulative Proposed Development Objective(s) A. Proposed Development Objective The development objective of the project is to increase the utilization of community nutrition and primary maternal and child health services in selected regions in the Recipient s territory. Components Component Name Cost (US$ Millions) Community mobilization for social and behavior change 2.50 Delivery of selected primary health care services 3.78 Capacity building for service delivery and results based financing 2.40 Sector Board Health, Nutrition and Population Institutional Data Sectors / Climate Change Sector (Maximum 5 and total % must equal 100) Major Sector Sector % Adaptation Co-benefits % Health and other social services Health 60 Health and other social services Other social services 40 Total 100 Mitigation Co-benefits % I certify that there is no Adaptation and Mitigation Climate Change Co-benefits information applicable to this project. Themes Theme (Maximum 5 and total % must equal 100) Major theme Theme % Human development Health system performance 25 Human development Nutrition and food security 35 Human development Child health 20 Human development Population and reproductive health 20 Total 100 viii

9 ... Policy Compliance Does the project depart from the CAS in content or in other significant respects? Yes [ ] No [ X ] Does the project require any waivers of Bank policies? Yes [ ] No [ X ] Have these been approved by Bank management? Yes [ ] No [ ] Is approval for any policy waiver sought from the Board? Yes [ ] No [ X ] Does the project meet the Regional criteria for readiness for implementation? Yes [ X ] No [ ] Safeguard Policies Triggered by the Project Yes No Environmental Assessment OP/BP 4.01 Natural Habitats OP/BP 4.04 Forests OP/BP 4.36 Pest Management OP 4.09 Physical Cultural Resources OP/BP 4.11 Indigenous Peoples OP/BP 4.10 Involuntary Resettlement OP/BP 4.12 Safety of Dams OP/BP 4.37 Projects on International Waterways OP/BP 7.50 Projects in Disputed Areas OP/BP 7.60 Legal Covenants Name Recurrent Due Date Frequency Recruitment of IVA Description of Covenant 30-Jan-2015 The Recipient shall, not later than six months (6) months after the Effective Date, recruit an Independent Verification Agent (IVA) in accordance with the provisions of Section III of Schedule 2 to this Agreement, and with qualifications, experience and terms of reference acceptable to the Association. Name Recurrent Due Date Frequency Recruitment of External Auditor Description of Covenant 30-Jan-2015 The Recipient shall recruit, not later than six (6) months after the Effective Date, the external auditor referred to in Section 4.09 (b) of the General Conditions in accordance with Section III of Schedule 2 of the Financing Agreement and pursuant to terms of reference satisfactory to the Association, to carry out such functions as set forth in the Project Operations Manual. Name Recurrent Due Date Frequency Roll-out of GIFMIS 30-Sep-2015 X X X X X X X X X X ix

10 . Description of Covenant The Recipient shall, not later than fifteen (15) months after the Effective Date, adopt, and thereafter use at all times during the implementation of the Project, the Gambian Integrated Financial Management Information System (GIFMIS) as the Project s financial information system. Conditions Name Execution of Co-financing Agreement Description of Condition Type Effectiveness The Co-financing Agreement has been executed and delivered and all conditions precedent to its effectiveness or to the right of the Recipient to make withdrawals under it (other than the effectiveness of this Agreement) have been fulfilled. Bank Staff Team Composition Name Title Specialization Unit Wolfgang M. T. Chadab Senior Finance Officer Disbursement CTRLA Liba C. S. Feldblyum Operations Analyst Environmental Safeguards AFTN2 Nicole Hamon Language Program Assistant Program Assistance AFTHW Linda K. English Sector Leader Human Development AFTHD Menno Mulder-Sibanda Senior Nutrition Spec. Team Lead, Nutrition AFTHW Gaston Sorgho Lead Public Health Specialist Public Health AFTHD Raja Bentaouet Kattan Sector Leader Human Development AFTHD Mamadou Mansour Mbaye Consultant Procurement AFCF1 Ali Winoto Subandoro E T Consultant M&E AFTHW Helle M. Alvesson Consultant Gender AFTHW Yassin Saine Njie Program Assistant Program Assistance AFMGM Rifat Hasan Young Professional Public Health, M&E AFTHW Zuzana Boehmova Consultant Reproductive Health AFTHW Maya Abi Karam Senior Counsel Legal Assistance LEGAM Haidara Ousmane Diadie Senior Health Specialist Health AFTHW Ronald Upenyu Mutasa Operations Officer Results-Based Financing AFTHE Jos J.H.J Dusseljee Consultant Results-Based Financing AFTEW Ngor Sene Financial Management Specialist Financial Management AFTMW Elizabeth Hassan E T Consultant Legal Assistance LEGVP Faly Diallo Financial Officer Disbursement CTRLA Michael Vaislic Consultant Economics AFTP1 x

11 I. STRATEGIC CONTEXT A. Country Context 1. The Gambia is a small country in West Africa with a population of approximately 1.9 million (2013). The population has been growing at a fairly high rate of 3.3 percent per year over the last decade. The Gambia is a low income country with average per capita Gross National Income (GNI) estimated at US$510 (2012) which is less than half of the sub-saharan African average of US$1,255. In the 2011 Human Development Index, the country was ranked 168 out of 187 countries. Life expectancy at birth for the average Gambian is 58 years. 2. Poverty in The Gambia is pervasive in spite of a noticeable decline of overall poverty rates during the last decade. The overall poverty head count index is estimated at 48.4 percent (upper poverty line: US$1.25 a day), down from an estimated 58 percent. The Gambia has had strong economic performance in recent years with an average annual real GDP growth rate of 6-7 percent during However, economic growth in The Gambia no matter how impressive has not been inclusive. There are large regional variations of poverty within The Gambia, with rural areas recording a substantially higher poverty head count (73.9 percent) compared with urban areas (32.7 percent). 3. Given a relatively undiversified economy, the country remains highly vulnerable to external shocks, with heavy dependence on rain-fed crops for agricultural production, imports for food security, and tourism receipts and remittances for foreign exchange earnings. The Sahel drought caused big losses in agricultural crop production, with related impacts on household food security and nutrition, the availability of seeds for the following agriculture season, and the balance of payments. B. Sectoral and Institutional Context 4. The Gambia s performance on MDGs 1c, 4 and 5 has been mixed. While better off than the sub-saharan African average for under-five mortality rate (U5MR) and maternal mortality ratio (MMR), when compared to sub-regional peers like Ghana and Senegal, The Gambia s performance is lagging behind. U5MR and MMR have declined since 1990, but the progress has been modest in relation with the millennium development goals (MDG) 1c, 4 and 5 (Table 1). Preliminary data from the 2013 Demographic Health Survey (DHS), if confirmed, would show encouraging results for U5MR having dropped to 54 per 1,000 live births. No such indication exists for maternal mortality or nutrition. The preliminary data from the 2013 DHS shows no change in underweight prevalence, i.e., 16 percent. According to the 2013 State of the World s Mothers (Save the Children 2013), The Gambia ranks 170 out of 176 countries on the Mother s Index just above Mali, Niger and Central African Republic but behind countries like Chad, Guinea-Bissau and Nigeria. 1 1 Indicators of the 2013 Mother s Index include: (i) Lifetime risk of maternal death; (ii) Under-5 mortality rate; (iii) Expected years of formal education; (iv) Gross national income per capita; and (iv) Participation of women in national government 1

12 Table 1 Trend in MDG 1c, 4 and 5 in The Gambia /12 MDG target Maternal Mortality (per 100,000) Under-5 Mortality (per 1,000) Underweight Malnutrition (percent) Source: Trends in Maternal Mortality , WHO 2012; Child Mortality Report, UNICEF 2013; WHO Global Database and SMART 2012, National Nutrition Agency, Maternal health indicators continue to perform poorly. Total fertility rate (TFR) appears to have increased to 5.6 children per woman while contraceptive prevalence rate (CPR) has dropped to 9 percent (Table 2). Unmet need for family planning is estimated at 22 percent. The percentage of women who had skilled attendance at delivery 57 percent has remained unchanged since At least one antenatal care (ANC) visit by a skilled provider, nearly universal in 2005/06, has dropped to 86 percent (2013) and does not vary by level of education. The recommended four visits were completed by only 72 percent of women in 2010 (MICS 2010). Moreover, most women do not have their first ANC in the first trimester, jeopardizing healthy outcomes for both mother and child. The 2011 Maternal and Perinatal Audit of Royal Victoria Teaching Hospital highlighted delayed access to referral services by pregnant women as a major contributing factor to high maternal mortality. Furthermore, teenage pregnancies are common, resulting in a high adolescent fertility rate of 118 per 1,000 and nearly 20 percent of adolescent girls age having begun childbearing (MICS 2010). Pregnancy in adolescence raises the risk for maternal mortality, morbidity and child malnutrition. Utilization of health services by youth is low, and few facilities offer youth-friendly reproductive health services. Table 2 Health outcome indicators, 2005/06 and 2010/ / /13 Trend * Women s health Marriage before the age of 18 years No change Intermittent preventive treatment (IPT) for malaria Improvement Skilled attendance at delivery No change Antenatal care (at least one visit) Deterioration Contraceptive prevalence rate (any method) 13 9 Deterioration Total fertility rate Deterioration Child Health Neonatal tetanus protection Deterioration Exclusive breastfeeding under six months Improvement Minimum feeding frequency Deterioration Vitamin A supplementation in children 6-59 months Deterioration Measles immunization by age 12 months No change Oral rehydration treatment Improvement Children under age 5 sleeping under insecticide-treated bed nets No change Antimalarial treatment of children under Deterioration Care seeking for suspected pneumonia No change * No change refers to any difference that is less than 5 percent difference of the 2005/06 value Source: MICS 2005/06, 2010, DHS 2013 Preliminary Report and World Bank Development Indicator database 2

13 6. Improvement can be seen in some but not all child health indicators. Vitamin A supplementation increased considerably between 2000 and 2005 but has since dropped (Table 2). While there is still room for further improvement, use of oral rehydration therapy with continued feeding has improved between 2005 and Similarly, exclusive breastfeeding rate has improved and is now 47 percent. The percentage of children sleeping under insecticide-treated nets has stagnated at 47 percent. Importantly, several outcome indicators are deteriorating, most notably, feeding frequency, vitamin A supplementation, and antimalarial treatment of children under five with fever. 7. Nutrition and health outcomes vary strongly between the rural eastern regions and urbanized western regions of The Gambia. Table 3 shows a few selected health and nutrition indicators by Region and Local Government Area (LGA) of The Gambia (map of The Gambia available in Annex 7). Table 3 Health and nutrition outcomes by Local Government Area Under-5 mortality Infant mortality Stunting Institutional delivery Upper River Region Basse LGA Central River Region Janjanbureh LGA Kuntaur LGA North Bank Region Kerewan LGA Lower River Region Mansa Konko LGA West Coast Region Brikama LGA Banjul Region Kanifing LGA Banjul LGA Source: MICS 2010, DHS 213 Preliminary Report 8. Quantitative and qualitative assessments conducted at the household and facility levels in preparation of this project indicate a number of barriers to better health and nutrition outcomes. 2 Table 4 summarizes the demand- and supply-side barriers identified by the assessments for some key indicators. The majority of demand-side constraints occur at the household or community level (except for attitude of providers toward patients) and is related to cultural obstacles; cost; inconvenience; and inadequate understanding about risks and benefits of seeking care or adopting a particular behavior. On the supply-side, the reasons for poor outcomes stem from the health system experiencing insufficient financing; inconsistent infrastructure, equipment and supplies; and inadequate training and motivation of health providers. 2 A Rapid Assessment of the Gambia PHC and Community Health & Nutrition Structures: a Mixed-methods approach 2014; A Rapid Assessment of Household Health Expenditures and Health Seeking Behaviors

14 Table 4 Barriers to utilization and/or adoption of key health services and behaviors Level Demand-Side Supply-Side Skilled attendance at delivery (57%) Household/ Community Cultural norms regarding childbirth Perceptions of danger/severity/need to seek care Availability of or cost of transportation Inadequate supplies for community agents to provide services (e.g. weighing scales, sanitary materials, record books) Health System Attitudes of providers toward patients Lack of consistent supply of electricity, equipment, drugs and commodities, fuel; ANC, especially in 1 st Trimester Household/ Community Cultural beliefs on the importance of hiding pregnancy during the early stages Contraceptive Prevalence Rate (9%) Household/ Community Health System High desired fertility, especially of men Discomfort with family planning Modern family planning methods difficult to use Exclusive Breastfeeding Under 6 Months (47%) Household/ Community Health System Unawareness of the adequacy of breast milk to keep the child hydrated Common perception of insufficient milk when a child cries or when a mother feels weak, tired or hungry Perception of spoiled milk, e.g., when mother becomes angry or ill Inadequate community support for the practice of exclusive breastfeeding Vitamin A supplementation in children 6-59 months (73%) Household/ Community Preference for home-based treatment with traditional healers Inadequately trained and poorly motivated medical personnel Inequitable distribution of trained personnel Low allocation of financial resources at PHC level Unavailability of method mix Lack of youth-friendly services Counseling on exclusive breastfeeding not universally provided at health centers 9. In addition, the Ministry of Health and Social Welfare (MOHSW) with support from UNICEF embarked on the development of the Health Sector Investment Case for accelerating progress towards the MDGs ( ) using the Marginal Budgeting for Bottlenecks tool (MBB). This analysis included (i) a thorough assessment of Gambia s existing health system; 4

15 (ii) analysis of a sample of interventions delivered at the community, outreach, and clinical levels of the health system for identifying major bottlenecks to scaling up; and (iii) identification of priority health systems strengthening strategies for the attainment of the health-related MDGs. 10. The MBB analysis showed that The Gambia s slow progress towards health- and nutrition-related MDGs can be largely attributed to five interrelated factors: (i) lack of a comprehensive human resource strategy; (ii) inadequate (or inconsistent) equipment, supplies, and commodities; (iii) inadequate community mobilization for maternal and child health and nutrition; (iv) uneven access to and utilization of nutrition and health services by socioeconomic status and by geographic region; and (v) biased intra-sectoral allocation of the health budget where 54 percent of the national budget remains at tertiary level (made up of hospitals and a Teaching Hospital) and less than 20 percent of funds go to the decentralized level. Based on this analysis, a number of health systems strengthening strategies were identified: (i) revitalize primary health care (PHC); (ii) initiate Child Health Weeks; (iii) improve communication for behavior change; (iv) improve supply chain management; and (v) address equity. 11. The Gambia requires significant efforts to make progress on undernutrition. Stunting increased between 2000 and 2005 from 24 to 28 percent (WHO Global Database on Child Growth and Malnutrition) after which it came back down to 25 percent in Furthermore, the percentage of children suffering from stunting varied by socioeconomic wellbeing with those in the poorest quintiles faring worst. Wasting declined marginally between 2000 and 2005 before increasing to 12 percent in The percentage of underweight children actually increased steadily between 2000 and The lagging performance on nutrition indicators is compounded by an ongoing food crisis in the Sahel region; to achieve meaningful progress in this area, high-impact community-based interventions for nutritional outcomes at both the household and community levels are critical. 12. In response to the lagging performance on nutrition outcomes, the World Bank and the Government of The Gambia agreed in December 2009 on a Non-Lending Technical Assistance (NLTA) with the objective to strengthen the institutional, organizational and financial capacity to improve the nutritional status of the Gambian people. The two-year NLTA was implemented by the National Nutrition Agency (NaNA) and aimed at strengthening the link between NaNA s institutional capacity and effective implementation of nutrition policies in the Gambia. To that effect, NaNA finalized and validated the new National Nutrition Policy ; elaborated and costed the Strategic Plan for Nutrition ; and produced the Nutrition Business Plan. 13. In the aftermath of the global food price and economic crises, NaNA obtained a US$3 million grant from the World Bank for a Rapid Response Nutrition Security Improvement Project ( ) to protect the nutritional status of women and children. Part of the grant served to strengthen institutional capacity. This project closed in July 2013 and has performed satisfactorily on the development objective and project implementation progress, including financial management and procurement. The development objective was to promote healthy behaviors for maternal nutrition and child growth and improve access to selected therapeutic and preventive public health and nutrition services to vulnerable populations, in particular children under five and pregnant and lactating women in poor rural areas. 5

16 14. The poor performance of the health service delivery system on maternal and child nutrition and health outcomes point to an operationally weakened and under-funded PHC system and inadequate linkages between communities and the health sector. Total expenditure on health per capita in 2010 was US$26 and the total expenditure on health was six percent of GDP. General government expenditure on health as a percentage of total health expenditure is 51 percent; out-of-pocket expenditure by poor families 24 percent; and external resources 25 percent. While household out-of-pocket spending represents the third largest share of health financing sources, the financial burden of accessing health care by the poor is significant in view of the fact that households spent on average US$5.50 per disease episode in a four week period preceding the Out-of-Pocket Expenditure Survey in November The high poverty head count at 48.4 percent (upper poverty line: US$1.25/day), makes the out-of-pocket expenditure levels beyond the reach of a significant proportion of households. The financial burden in accessing health care affects those in rural areas more in view of the fact that 73.9 percent of the poor live in rural areas compared to 32.7 percent in urban areas. 4 Thus, most of the population, especially those not formally employed, remains highly vulnerable to financial risk from health care expenditures. 15. The limited central government spending on health has resulted in a transfer of the financial burden onto patients in the form of out-of-pocket expenditures. Although Government policy is to provide free basic services in particular maternal and child health services households fund food, transportation and laboratory services, medicines and medical supplies where they are not available at the time of seeking care. 16. A Results-Based Financing (RBF) mechanism with a focus on preventive and primary care for health and nutrition was noted as a strategic step that could contribute to improving the maternal and child health and nutrition outcomes in The Gambia. 5 Strategic factors that favor the introduction of RBF to enhance community nutrition and PHC include: (i) the renewed interest in the MOHSW, with support from UNFPA, WHO and UNICEF, to scale-up the PHC service delivery system, including the village health system, and accelerate roll-out of prioritized high-impact nutrition interventions; (ii) the financing gap for high impact maternal and child health and nutrition interventions outlined in the recently completed Investment Case for Health 2013 to 2015 and Business Plan for Better Nutrition ; and (iii) the visibility of the mother and Baby Friendly Community Initiative (BFCI) managed by NaNA under the Office of the Vice President who is also Minister of Women s Affairs. 17. There is a strong commitment to learn from RBF programs by the Government. The Government has developed RBF experience in the education sector and recently started a pilot in the health and nutrition sector in the North Bank West Region to generate knowledge on what 3 Jallow C, Ceesay E. Out-of-Pocket Expenditure on Health. Sahel Invest Management International, Banjul, Integrated Household Survey, Gambia Bureau of Statistics, Banjul, RBF for health has been defined as a cash or non-monetary transfer made to a national or sub-national government, manager, provider, payer or consumer of health services after predefined results have been attained and verified. Payment is conditional on measurable actions being undertaken ( Many different forms of RBF exist including performance-based financing (PBF: fee for service conditional upon quality of care results are purchased from health facilities or community-level providers for provision of services); performancebased contracting (PBC: results are generally purchased from NGOs); conditional cash transfers (CCT: results are purchased from individuals or households or communities for utilization of services), among others. 6

17 mechanisms work best to foster social and behavior change at community level; reach low income or hard-to-reach families and young people; and enhance priority health and nutrition service delivery at the primary health care level. In preparation for the pilot, the MOHSW and NaNA have participated in the regional RBF implementation workshop in Zambia in May 2012 and exchanged visits to Zimbabwe and Rwanda in November 2012 to strengthen their understanding of RBF approaches and mechanisms. In addition, technical assistance (TA) from Rwanda was mobilized to help The Gambia prepare for the pilot implementation. 18. The pilot started implementation towards the end of November 2013 and will run for approximately a year after which it will be integrated into the scaling up of activities. Despite the fact that the pilot only started recently, already important findings are coming to the surface such as the change in attitude of health personnel, the increase in service utilization including deliveries in health facilities and antenatal care, a stronger emphasis on outreach and relations with communities, and the empowerment of communities with an increased interest in new knowledge on healthy behaviors and health service delivery. In June 2014, just before the main project is expected to become effective, a review of the pilot experience is planned with the objective of drawing lessons that can be applied to the scaling up of RBF approaches. C. Higher Level Objectives to which the Project Contributes 19. The overall objective of the project is to improve health and nutrition outcomes among women and children by focusing on the least served Regions. The project will support the long term objectives of reducing maternal and child mortality and undernutrition and thereby contribute to the attainment of MDGs 1c, 4 and 5. Improved health and nutrition improves human capital and produces more productive individuals who are better off economically. In addition, this project will be implemented in the worst performing regions in The Gambia improving their nutrition, health and development outcomes will bridge the gap with those better off, thereby, contributing to the goals of eliminating extreme poverty and boosting shared prosperity. 20. The project is fully aligned with the priorities of the Government which is to reinforce gains in welfare over the past five years in addition to sustaining recent economic achievements by accelerating growth and employment as laid out in the Program for Accelerated Growth and Employment (PAGE; ). The strategy identified widening access to health services as one of 10 principal challenges for national growth and development. Accordingly, improving human capital and social services, in particular access to and quality of health services and nutrition and food security interventions, are among the strategic priorities. These priorities are also reflected in the Joint Partnership Strategy which explicitly makes the case to support the Government in achieving improved outcomes in maternal and child health and nutrition. 21. The project complements other Bank-supported investment projects, notably those in agriculture (i.e., the West Africa Agriculture Productivity Program and the Commercial Agriculture and Value Chain Management Project), that impact on health and nutrition outcomes. A coordinated approach will create synergies between these different Bank-supported investment projects in health, nutrition, food security and agriculture. 7

18 II. PROJECT DEVELOPMENT OBJECTIVE A. PDO 22. The development objective of the project is to increase the utilization of community nutrition and primary maternal and child health services in selected regions in the Recipient s territory. B. Project Beneficiaries 23. This project will target women of reproductive age, including adolescents, and children under five focusing on the community level strategies which build on the integrated Baby Friendly Community (BFC) and PHC Strategies of NaNA and the MOHSW. This will be implemented in three Regions with some of the poorest performing indicators (e.g. the Upper River, the Central River and the North Bank West Regions). These three Regions currently account for one third of the total population. Over the five-year period of implementation, the project is expected to reach approximately 183,000 children under five and 180,000 women aged years, yielding a total of 363,000 direct beneficiaries of the Project. The interventions will provide support through RBF arrangements with women, Village Development Committees (VDC) and Support Groups, and health service providers. Similarly, supervision, guidance and monitoring support will be provided by Regional Health Teams (RHTs), potentially assisted by Multi-Disciplinary Facilitation Teams (MDFTs: teams of extension workers). C. PDO Level Results Indicators 24. The identification of results indicators to track the performance of the project in achieving the PDO was guided by the various dimensions that make up the PDO; i.e., outcomes in health and nutrition; women and children; and behavior change or service delivery. Accordingly, the following performance indicators have been identified; Percentage of children 0-6 months who are exclusively breastfed; Number of deliveries attended by certified midwives in the preceding year; Number of children aged 6-59 months who received a dose of vitamin A within the past twelve months; Number of women using modern methods of family planning in the preceding year; and Direct project beneficiaries (number); of which female (percentage). III. PROJECT DESCRIPTION A. Project Components 25. To achieve the expected improvement in health and nutrition outcomes this project will prioritize selected interventions directly linked to the reduction of maternal and child undernutrition, morbidity and mortality. Interventions will focus on strengthening community structures and the PHC system to enhance the quality and quantity of services by empowering individual women, communities (including community groups) and front line health workers to 8

19 improve uptake, participation, ownership, caring practices and accountability for maternal, reproductive and child health and nutrition. Innovative aspects of this project are the combined use of RBF approaches on the demand- and supply-sides and at the community and PHC levels to improve health and nutrition outcomes. 26. The proposed project is composed of three components as described in Table 5. Components 1 and 2 will apply RBF mechanisms to address demand- and supply-side challenges as well as social and behavioral issues for improving maternal and child health and nutrition outcomes, respectively. Component 3 will strengthen overall management capacity (including monitoring and evaluation) of communities, local government and the health system to effectively engage in results-based management. The roll-out of supply-side and demand-side interventions will be geographically coordinated to ensure operational costs and subsidy payments are kept within reasonable limits. Table 5 Summary of activities by component Component 1: Community mobilization for social and behavior change Component 2: Delivery of selected PHC services Component 3: Capacity building for service delivery and RBF Conditional cash transfers to communities and support groups Conditional cash transfer to individuals Social and behavior change communication (SBCC) Performance-based financing for health centers Startup support (including selected health care waste management measures) Capacity building M&E, operational research and verification Coordination and program management at all levels Performance contracts with RHT, HMIS, RBF Committee, and NaNA 27. Component 1: Community mobilization for social and behavior change (IDA US$1.06 million; MDTF-HRI US$1.44 million): This component will focus on communitybased promotion of key family practices (i.e., the 12 family and community practices that promote child survival, growth and development) 6 and health care seeking behaviors for improved maternal and child health and nutrition outcomes through: (i) Provision of conditional cash transfers to communities and village support groups (VSG) to increase demand for and utilization of health and nutrition services through counseling and timely referrals for life-saving health services (e.g., hygiene, sanitation, counseling on infant and young child feeding, delayed first pregnancy and child spacing, referral of pregnant women and children with danger signs to health centers); (ii) Provision of conditional cash transfers (CCT) to individual women to increase utilization of timely antenatal care; and (iii) Accompanying measures aimed at promoting behavioral changes and increasing demand to improve household practices related to health and nutrition through social and behavior change communication (SBCC; which includes technical advisory services and training). 6 Hill Z., Kirkwood B.R., Edmond K. Family and community practices that promote child survival, growth and development: A review of the evidence. WHO, Geneva (2004). 9

20 28. Activity (i): VDCs will sign an RBF contract with the RHT. Payments will be quarterly and/or six-monthly for achieved performance on predefined indicators. NaNA will verify the achievement of results and Community-Based Organizations (CBO) will counter-verify a sample of these results through patient-tracing and client satisfaction surveys. The list of incentivized indicators defined by NaNA and the MOHSW focus primarily on maternal and child health and nutrition. Achievement of SBCC targets will be verified through reliability assessment of routine monitoring reports and community surveys. In addition, equity criteria will be developed to reward geographically remote communities with larger payment amounts to compensate for the additional cost of mobilizing communities and delivering services. 29. VDCs can use their payments for operating costs, community mobilization and performance-based incentives to individual members of the Village Support Groups (VSG). 7 VDCs, which act on behalf of their communities, can use the cash for community development activities to attain results and benefit the wellbeing of women and children, according to the Financing Instructions and General Orders of the Government. Altogether, this component will finance results, training and workshops, communication, material and equipment (i.e., startup costs) and operating costs. 30. Activity (ii): CCTs will be provided to women for completing their first ANC visit during the first trimester and following through with at least three more ANC visits in the course of pregnancy. Use of the services will be verified by NaNA using health center records. Once the data has been verified, payments will be transferred to women by the health centers where the services were provided. 31. Activity (iii) will focus on the implementation of SBCC strategies to accompany the other sub-components in order to have a comprehensive and sustainable approach to promoting behavioral changes and increasing demand for health care utilization. 32. Component 2: Delivery of selected primary health care services (IDA US$1.60 million; MDTF-HRI US$2.18 million): This component aims to support the delivery of selected nutrition and health care services at primary, and, where needed, referral health care levels, through: (i) provision of performance-based grant to health centers for the delivery of a predefined package of maternal and child health and nutrition services at primary and referral health care facilities; and (ii) provision of startup support for effective service delivery, including the implementation of selected health care waste management measures. 33. Activity (i) refers to a fee-for-services mechanism which includes quantity and quality payments for a defined package of maternal and child health and nutrition services. Payment will be triggered following quantity verification by NaNA. The final amount will be determined following quality verification by RHTs. Health centers will sign an RBF contract with the MOHSW RBF Committee and receive quarterly payments corresponding to their achieved performance based on both the quantity and quality of services delivered. The demand side financial barrier to access services will be reduced by eliminating the practice of requiring 7 VSGs are male and female members of the community (including Traditional Birth Attendants) who have supported implementation of the nutrition program at the community level, particularly the BFCI. 10

21 patients to pay user fees for the agreed package of services in public and not-for profit health facilities contracted under the project. The fee schedule takes into consideration: (i) the unit-cost of delivering the particular package of services; (ii) current coverage of interventions; (iii) disease burden and cost of accessing each of the prioritized services by users; (iv) interventions most prioritized by the MOHSW and NaNA; (v) labor intensity of each public health intervention; and (vi) whether the service will benefit from a parallel demand side incentive. 34. Challenges faced by facilities in remote areas result in higher costs to deliver services. The fee for service scheme will also take this into account by adjusting the fees upwards for the delivery of services in more remote areas. 8 A hardship factor will be integrated into the design of fee schedules and will be endorsed by the Project Steering Committee. The amount to be paid to individual health facilities under the service delivery contracts is illustrated in Annex Health centers can be Government-run or private (not-for-profit). NaNA will verify the achievement of quantity outputs. A quality assessment tool will be used by RHTs to assess the quality of services provided by the contracted health facilities each quarter. The tool has a broad variety of indicators such as cleanliness, quality of recordkeeping, availability of staff and supplies etc. In addition to the assessment of quality by RHTs, CBOs will be contracted by NaNA to undertake client tracer and satisfaction surveys with a view to: (i) verify the authenticity of patients and services reported by a health facility; and (ii) capture patient feedback regarding the services they received. While performance-based payments to the health centers are made on selected indicators, RHTs will also monitor the adequate delivery of nonincentivized services. Penalties will be applied in the event of incomplete reports on nonincentivized services or disproportionate bias towards the delivery of incentivized services. 36. Health centers can use their RBF payments for material and equipment, training, consulting services and operating costs, and staff bonuses that will ultimately improve service delivery. Facilities will have sufficient decision space for social entrepreneurship to use the performance payments to improve the demand and quality of services provided and this will be clearly stated in performance contracts. As part of the RBF contracting cycle, each health provider will develop a business plan which serves as a guide for future investments and use of RBF payments. The MOHSW RBF Committee will provide advice and support to health facilities to develop business plans as needed. RHTs will supervise health facilities to ensure that business plans are in place at the start of each contracting cycle. 37. Through intervention (ii), the project will provide start-up support to ensure a minimum level of service provision capacity. This will include implementation of selected health care waste management measures (e.g. incinerators, open pits for burning, etc.). To address bottlenecks that lie outside the control of facilities, higher-level RBF management structures (RHTs, MOHSW RBF Committee, etc.) will be involved in developing and modifying policies that will be conducive to overcoming those bottlenecks. 8 Objective remoteness criteria will be outlined in the next version of the Project Operations Manual (POM) once the pricing assessment report has been finalized. 9 A detailed pricing exercise was undertaken and the final fee schedule for RBF services will be updated in the POM once the report has been finalized. The fee schedule will be updated in line with intervals set in the POM. 11

22 38. The Project Operations Manual (POM) describes the key features of the RBF model including: (i) the approach to engage health facilities; (ii) the service package and fee schedule for primary care and referral level health facilities as well as the mechanism and timing for periodic updating of unit costs; (iii) the quality assessment tool; (iv) roles and responsibilities for the verification of results; and (v) penalties for misreporting, misuse of funds and other irregularities. The POM will be a living document that will be updated regularly based on lessons learnt during implementation. The first major updates to the POM will be after the review of ongoing pilot interventions which have been under implementation since November This review is scheduled for June Component 3: Capacity building for service delivery and results-based management (IDA US$1.02 million; MDTF-HRI US$1.38 million): This component will support: (i) strengthening the management capacity of key implementing entities including NaNA, MOFEA, MOHSW, MOHSW RBF Committee, health service providers, VDCs, VSGs, and RHTs for effective implementation of the RBF, including: (i) strengthening governance and strategic RBF management capacity; (ii) improving the Health Management Information System (HMIS); (iii) supporting community demand, organization and mobilization; (iv) social and behavior change communication strategy development; (v) institutionalization of RBF; (vi) training for RHTs on the use of quality supervision tools and innovative ways to improve verification and supervision; and (vii) mentoring and peer learning among RBF stakeholders, all through the provision of technical advisory services, training, and the acquisition of goods; (ii) monitoring and evaluation; verification of RBF activities including cost of the IVA and CBOs; and operational research, learning and knowledge management activities through the provision of technical advisory services and training; (iii) project implementation including project management and coordination, fiduciary management, oversight, and communications, through the provision of technical advisory services, training and operating costs; and (iv) ensuring effective management and implementation support of the RBF by the RHTs, HMIS, MOHSW RBF Committee, and NaNA by means of performance agreements. 40. Capacity building will be provided through: (i) long-term TA; and (ii) in-service and onthe-job training and consulting services. To the extent possible, capacity building will use incountry peer learning and south-south learning from countries with mature RBF programs. This component will also strengthen the capacity of the MOHSW in RBF, procurement and financial management. Immediate capacity building priorities from the above list of activities are: (i) TA, training and on-the-job learning for verification; and (ii) training for RHTs and MOHSW RBF Committee to develop and use a RBF quality supervision tool. 41. In view of the importance of HMIS in the implementation of core RBF functions, key aspects that will be prioritized in HMIS improvements include building a core District Health Information System (version 2; DHIS2) 10 team in MOHSW and NaNA. Investments in strengthening HMIS will enable NaNA to establish a web based payments database which will be linked to the DHIS2 platform. MOHSW has embraced information technology and its 10 DHIS 2 is a free and open source health information system for the collection, analysis and reporting of health data. It is implemented in many developing countries and allows decentralized access to and analysis of data. 12

23 ongoing partnership with the University of Oslo in rolling out DHIS2 provides a strong foundation for targeted TA and investments in HMIS infrastructure, web connectivity, software and technical skills critical for the roll-out of the project. 42. The RBF program will be designed to enable learning through M&E systems, operational research, documentation, knowledge management and process and impact evaluations to capture the effect, efficiency and implementation challenges of the program with respect to health and nutrition outcomes, ownership, cost-effectiveness, and other aspects of community mobilization and health system strengthening. The rolling out of process evaluations will be a key feature of the project to strengthen learning from RBF implementation. 43. Finally, performance contracts will be used to support essential RBF supervision and management functions of the RHTs, HMIS, MOHSW RBF Committee, and NaNA (see Annex 3). RHT responsibilities include the monitoring and supervision of health centers, quality verification of health centers and management of contracts with VDCs. The MOHSW RBF Committee has to manage performance-based contracts with health facilities and RHTs, as well as ensure minimum quality and service delivery standards; NaNA will manage the output payment budget as well as IVA, client tracers and LQAS contracts, and fiduciary management reporting. B. Project Cost and Financing 44. The project will be financed by US$3.68 million equivalent of IDA and US$5.0 million from the MDTF-HRI. Table 7 provides the allocation of the financing by component. Table 6 Project budget and IDA financing by Component actions Component Project Cost IDA Financing MDTF-HRI financing % IDA Financing Community mobilization for social and behavior change % Delivery of selected PHC services % Capacity building for service delivery and RBF % Total C. Lessons Learned and Reflected in the Project Design 45. The approach in The Gambia stands out from many other RBF experiences by going beyond supply-side health service delivery and using RBF mechanisms to incentivize community level improvements for maternal and child wellbeing, improve health care seeking behaviors, and strengthen the link between communities and health centers. The focus on community mobilization, social change and demand-side interventions suits the context of The Gambia where community structures are well integrated with health service provision. A pilot experience is currently being implemented in the North Bank West Region where some of the 13

24 community level RBF mechanisms are being tried and refined, including the use of the Lot Quality Assurance Sampling (LQAS) method for the verification of the exclusive breastfeeding rate at community level. Early results from the pilot indicate an uptake in service utilization in health facilities, increased motivation of staff, innovative solutions including community outreach, improved attitude of providers toward clients, innovative mobilization at community level, and increased demand from communities regarding health knowledge. The Gambia will bring significant added value to the global learning on RBF through its unique approach of combining demand- and supply-side interventions and focus on operational learning during implementation. 46. An important lesson learnt from projects using CCT approaches for social purposes is the need to communicate extensively on the RBF objective, the justification, the rules of the game, and the transactions in a way that leaves no room for either cheating or coercion. Component 1 allocates significant amounts of resources to SBCC on both health and nutrition issues and the RBF approaches. Lessons on the design of an integrated RBF package of services that includes maternal, child health and nutritional interventions have been learned from other contexts. IV. IMPLEMENTATION A. Institutional and Implementation Arrangements 47. The two principal institutions responsible for project implementation are NaNA and the MOHSW. Both MOHSW and NaNA work through the RHT to oversee community mobilization and service delivery. The MOHSW RBF Committee and RHT will be the purchaser and regulator of services. NaNA will be the fund holder for the project. The RBF Committee in the MOHSW will oversee the implementation of the various maternal and child health activities to be carried out by the different technical units (Directorates, Units) through the Director of Health Services. Health Centers and VDCs will be the providers of services. Table 8 indicates the entities that will perform each RBF function. Table 7 RBF functions and responsible entities Function/Role Purchaser and Regulator Service provider Fund holder, Payer, Quantity Verifier Quality Verifier External Verifier Responsible Entity MOHSW (RBF Committee), RHT Health centers, VDCs NaNA RHTs, CBOs IVA, CBOs 48. As fund holder, NaNA will ensure the fiduciary management for the project, including procurement. NaNA also has a higher mandate of multisectoral coordination for improved nutrition. Accordingly, the project can be linked to developments in other sectors that influence health and nutrition outcomes such as the investments in agriculture and food security. To ensure effective coordination between the MOHSW and NaNA, a Project Implementation Committee (PIC), composed of members from the two institutions, has been set up since the pilot learning 14

25 experience. The PIC is chaired by the Project Coordinator who sits in NaNA. The PIC is responsible for the development of annual work plans and budgets, coordinate and review progress implementation of the project, conduct regular monitoring and supervision, monitor and score RHT contracts, provide implementation support, select external verification agents and client tracers including CBOs, and prepare quarterly and annual reports. Key day-to-day project implementation functions will be ensured by the Project Coordinator, the Project Facilitator, the Financial Management Specialist, the Procurement Specialist and the M&E Officer of NaNA. In addition, the Project Team is directly supported by the PHC Focal Point, RCH Specialist and the Health Economist of the Ministry of Health and Social Welfare. Project implementation will be overseen by a Steering Committee composed of MOFEA, MOHSW, NaNA, the Office of the Vice President, and the Ministry of Regional Government, Land and Traditional Rulers. The institutional arrangements are shown in Figure 1. Figure 1: Project implementation arrangements 49. The verification of results will include an internal and an external verification and responsibilities for these will be shared among a number of responsible parties. Quantity verification will be carried out by NaNA while quality verification will be the responsibility of RHTs and CBOs. The external verification will involve the IVA and CBOs. The IVA will conduct periodic technical and financial audits. The periodicity will be higher in the first two years of project implementation (i.e., every six months) after which the external verification will be reduced to one per year. CBOs will be hired to conduct the counter verification and the community verification (see Table 9). 15

26 Table 8 Internal and external verification arrangements Internal Verification Quantity Data Verification: NaNA Verification Teams check the quantity of services by looking at the health center registers and tally sheets, VDC reports and payment claims. A sample of health centers and communities (VDCs) undergoes quantity verification every month. In the initial phase, the verification team will strive to cover 100 percent of the facilities and communities in a quarter. Depending on project performance, this can be reduced to an agreed sample after two years of implementing RBF by various actors in The Gambia. Quality Verification (for health center contracts): MOHSW represented by RHT checks the professional (medical) quality verified by performing random spot checks to ensure adherence to set protocols and standards of care as defined by the RBF supervision checklists and general checklists used in The Gambia for health center supervision (100% of facilities undergo quality verification every quarter). 75 percent of the quality score will be based on RHT supervision for quality. External verification Audits: An independent verification agency (IVA) performs financial and quality audits at all operational levels from the central to the community-level (including: NaNA as fund holder; MOHSW as regulator; the RBF Committees as purchasers; and health centers and VDCs as providers, by random spot checks (a sample of health centers, VDCs and VSGs is audited externally). The independent organization will use datasets from CBO client tracer surveys for its verification purposes. The IVA will also select a small sample of the patients verified by CBOs and undertake counter checks to ensure the CBOs undertook the verification processes objectively and reported accurately on patients feedback. The IVA will undertake spot checks for women beneficiaries who access demand side services. IVA s technical focus and sample size will be defined in TORs to be drafted by the Working Group and cleared by the Bank. Community Verification: CBOs will be contracted by NaNA to check the authenticity of the patients reported by providers and to evaluate patient satisfaction (a sample of patients are traced and administered a patient satisfaction survey). CBOs will work with the NaNA verification teams to compile patient tracer and satisfaction scores which will contribute to 25 percent of the aggregate quality score that health centers will receive. B. Results Monitoring and Evaluation 50. The project will include a comprehensive routine monitoring system and rigorous evaluation that focus on: (i) monitoring the activities to ensure that they are implemented as planned (i.e. delivery of inputs, process and outputs); (ii) measuring the progress towards achieving the outcomes; and (iii) setting up a mechanism that will allow the use of findings from routine monitoring for corrective actions during the implementation; and (iv) measuring the impact of the program on key health and nutrition outcomes. The RBF mechanism entails intense ongoing data reporting, review and verification. Prompt and accurate self-reported and externally-verified data is key to the implementation of RBF. Detailed monitoring and evaluation (M&E) plans will be developed as an overall guidance of the project s M&E activities and include results frameworks, routine monitoring and verification system, evaluation plan, standardized data collection instruments, key information products, strategies for dissemination and use of M&E information to improve results. 16

27 51. The routine monitoring and verification system will include a standardized mechanism for data reporting, technical verification and counter-verification, data analysis, monitoring and supervision procedures, and feedback mechanism to community. For data reporting, health facilities and community representatives (VDCs, VSGs) will be collecting data based on the indicators to be incentivized and submit these to the RHT at regular intervals using standardized data collection tools. An information flow matrix that describes in detail the responsibility of each project actor, data collection tools, planned use of data and timeframe and delivery schedule will be developed. 52. Thorough internal and external verification arrangements will be put in place, including internal quantity and quality verification undertaken by NaNA and RHTs, external financial and quality audits undertaken by IVA and CBOs, and beneficiaries satisfaction verification undertaken CBOs. A key investment of the project will be to build a culture of internal reviews at various levels of the project implementation structure. Evidence from countries with advanced RBF projects shows that internal reviews amongst health providers and their supervisors has greater benefits as it enables internal peer learning and joint planning to improve performance. Internal reviews of data can also serve as a form of peer pressure amongst contracted health providers and VSGs as performance data will be shared widely across a region. 53. For monitoring and supervision, health facility and community monitoring checklists will be developed for use by the RHT to monitor the implementation of the project, including health care waste management. Supervision will be carried out on a regular basis by the RHT and PIC. The emphasis will be on using the monitoring and supervision findings to improve quality of implementation. As part of RBF management, community nutrition data information system will be set up based on the synergies with the existing data information system and tools, e.g. HMIS, Community Registers, and the Nutrition Data Base. 54. The comprehensive evaluation plan will include both process and impact evaluations using various methods as necessary. It aims to enable a learning process that will capture the effect and efficiency of the program on health and nutrition outcomes, ownership, costeffectiveness, and other aspects of community mobilization and health system strengthening. Both quantitative and qualitative approaches will be utilized, and periodic process evaluations will be a key feature of the project to strengthen learning from RBF implementation to determine now only whether implementation is working but also how it is progressing. 55. The (mixed method) impact evaluation will be prospective, randomized and controlled to allow for measuring impact attributable to the interventions. The intervention and control areas will be selected using certain criteria, e.g. access to health services, existing health and nutrition status. The impact evaluation will likely focus on the impact of the demand-side incentives to communities in addition to the supply-side incentives to facilities. Accordingly, the following arms are being considered; (i) control communities not implementing any interventions; (ii) communities implementing only supply-side interventions; and (iii) communities implementing supply-side and community-level interventions. If, following the findings from the pilot, the CCTs to individual women are included, then this will be an additional arm to measure whether there is an additional impact on ANC above and beyond the supply-side and community-level interventions. 17

28 56. The process evaluations, to be conducted during project implementation, will address different operational features in terms of effectiveness and efficiency. Specifically, it will gather information on the delivery and design of the different components of the program; identify bottlenecks or constraints and possible solutions to improve implementation of the program; and explore the perceptions of different stakeholders about the effectiveness and quality of services provided and their roles and responsibilities within the project structure. The process evaluations will provide insights on organizational and behavioral changes as well as how quality of implementation affects the achievement of results indicators. C. Sustainability 57. There is the risk of financial unsustainability of the RBF approach. To ensure sustainability the following is being done: (i) pricing RBF services at levels consistent with health and nutrition financing capability in the country; and (ii) investment in technical and institutional strengthening of national, regional and community structures to ensure domestic capacity to continue RBF interventions beyond the initial Bank financing. The Bank will use its leverage to advocate for increases in allocations for health and nutrition financing by the treasury. The Bank will undertake analytical work to support the Ministry of Finance, NaNA and MOHSW to identify the extent to which fiscal space in the national budget exists and can be used to introduce domestic financing for RBF mechanisms based on evidence of success and lessons learned. Donor dialogue is being scaled up by NaNA and MOHSW in close collaboration with the Bank to identify opportunities for donor co-financing in the short-to-medium term. 58. The team has extensively engaged with the MOHSW, MOFEA, NaNA and the Vice President s Office to ensure that the proposed RBF mechanisms are well grounded in the current PHC and BFC strategies. As part of the policy dialogue, the team will continue to engage with the MOHSW, NaNA, MOFEA and the development partners to discuss the issue of the financial sustainability as part of the larger discussion of health and nutrition financing. Also important is the liaising of the sector policy dialogue with the general economic policy dialogue to ensure that the various development reforms are mutually reinforced. The government is starting to show commitment by allocating US$0.2 million for project management. 59. The project will design some of the RBF approaches as Rapid Results Initiatives whereby the RBF incentive will be part of a process to solve bottlenecks and improve community and health system performance in a defined period of time after which other indicators and performance bottlenecks can be addressed. The possibility of sanctions on incentives if earlier RBF indicators (currently non-incentivized) suffer is being monitored in the pilot. 18

29 V. KEY RISKS AND MITIGATION MEASURES A. Risk Ratings Summary Table Risk Category Stakeholder Risk Implementing Agency Risk Rating Moderate - Capacity Moderate - Governance Substantial Project Risk - Design Substantial - Social and Environmental Low - Program and Donor Low - Delivery Monitoring and Sustainability Moderate Overall Implementation Risk B. Overall Risk Rating Explanation Substantial 60. The overall risk is rated as Substantial. The main risks stem from the fact that: (i) RBF represents a new approach in health financing; (ii) the health sector has been experiencing instability around concerted implementation of health policies and programs as a result of high staff turn over both at the central and operational levels; (iii) the design includes several innovative features such as demand-side and community-based incentives; and (iv) two government agencies are involved in the implementation: a situation that requires close interinstitutional coordination. As a counterbalance to the risks, it is worth mentioning that the client is: (i) gaining operational experience with the various proposed RBF approaches through a pilot project supported by an additional MDTF-HRI Grant; and (ii) receiving TA from expert consultants from Rwanda. VI. APPRAISAL SUMMARY A. Economic and Financial Analysis 61. Interventions, which will be financed by this project, will lead to the targeting of resources to the most vulnerable segments of society, and specific high-impact interventions benefiting young children, adolescents and pregnant women will help improve the chances of these groups to rise out of poverty and contribute to the growth of the economy through higher labor productivity as adult workers. These economic benefits have been documented in economic and scientific studies in many developing countries. Estimates from a number of studies in the last 20 years indicate that the economic returns of nutrition interventions (including growth monitoring, micronutrient supplementation, salt iodization, etc.) rank among the highest in comparison with other developmental interventions. These results are achieved by the high productivity-enhancing effects of nutrition programs. Iron supplementation for example improves worker productivity, and iodine improvements increase cognitive ability (higher IQ) of 19

30 children and adults. The 2008 and 2012 Copenhagen Consensus by some of the world s leading economists that looked at the best investments concluded that nutrition investments, notably micronutrients and community nutrition, generate returns among the highest of 30 potential development investments. 11 Investments in micronutrients were rated above those in trade liberalization, malaria and water and sanitation. Community-based programs are also costeffective in preventing malnutrition. Overall the benefit-cost ratios for nutrition interventions range from 5 to The proposed components all build on on-going Government policies and are aimed at providing short term financing and associated TA to improve the efficiency and reach of these programs. 62. Addressing maternal and reproductive health brings dividends in both the short and long terms. The package of services included in the Project is technically sound and consistent with a series of articles in The Lancet which recommends priority, high-impact interventions to reduce child and maternal mortality rates. Worldwide, pregnancy-related conditions and sexually transmitted infections (STIs) account for one-third of the global burden of disease among women of reproductive age and one-fifth among the total population. Among women of reproductive age in Sub-Saharan Africa, for example, two-thirds of the disease burden for women of reproductive age is attributable to sexual and reproductive health problems. AGI and UNFPA calculate that 250 million years of productive life are lost each year to death or disability resulting from poor sexual and reproductive health (Cohen 2004). Delaying first birth and spacing subsequent births result in a higher likelihood of women staying in, having more employment opportunities, and participating politically in their communities. Improved maternal health means fewer orphans and more time for and greater ability of mothers to provide appropriate childcare. One of the most cost-effective interventions is family planning (US$1.55 per new user per year) which can prevent up to one-third of all maternal deaths by delaying childbearing, spacing births, avoiding unintended pregnancies. Family planning can also reduce infant mortality and morbidity through birth spacing and improve adolescent health by reducing high risks of pregnancy-related deaths. For every US$1 invested in family planning, the future savings are as high as US$4 in Zambia, US$7 in Bangladesh and US$8 in Indonesia. Hence, the returns on investment are high especially when integrated with maternal and child health services as in this project. 63. With the above in mind, an economic analysis was undertaken for the project, using different methodologies for the separate components. The standard cost-benefit analysis (CBA) was used for Component 1; the Marginal Budgeting for Bottlenecks (MBB) tool was used for a costing analysis of Components 2 and 3. The detailed methodology, assumptions and calculations can be found in Annex Component 1: The direct beneficiaries of the project s Component 1 are children under the age of 5, adolescent girls, and pregnant women in the Upper River, Central River, and North Bank West Regions. To avoid double-counting benefits (e.g. those that accrue 11 The Copenhagen Consensus 2012 Expert Panel finds that fighting malnourishment should be the top priority for policy-makers and philanthropists. Nobel laureate economist Vernon Smith said: One of the most compelling investments is to get nutrients to the world s undernourished. The benefits from doing so in terms of increased health, schooling, and productivity are tremendous Repositioning Nutrition as Central to Development: A Strategy for Large-Scale Action. World Bank, Washington,

31 intergenerationally, adolescent girls who become pregnant during the course of the project), the CBA was restricted to benefits gained by children under age 5 years only. Benefits to adolescent girls and women of reproductive age (15-49) who will benefit from improved reproductive and maternal health are not included. This implies that the estimated benefits are underestimated. 65. The analysis focuses on stunting because chronic undernutrition is an indicator of the final nutritional status of children according to the UNICEF conceptual framework. Evidence indicates that children under the age of 24 months who are stunted would earn significantly lower incomes throughout their productive lives. Thus, the benefits of reducing stunting in the project areas are measured by the increased income-earning capacity of the beneficiaries for whom stunting is prevented. The most recent empirical estimates of the negative effects of stunting on worker productivity and adult earnings range from 10 to 20 percent Assuming 80 percent project coverage, 15 percent earnings premium from reduced stunting after accounting for expected mortality risk, no effect on stunting for better-off households, and 5 percent discount rate, the results of this economic analysis yields a net present value (NPV) of US$1.5 million and Benefit/Cost (B/C) ratio of 2.0 (Table 10). 14 A sensitivity analysis was conducted to assess robustness of the estimates. In Scenario 2, the earnings premium due to stunting, were increased from 15 to 20 percent (as estimated by Grantham- McGregor and colleagues) which yields an NPV of US$2.5 million and a B/C ratio of 2.7. In Scenario 3, the earnings premium is reduced to 10 percent which yields an NPV of US$0.5 million and a B/C ratio of 1.3. Thus, the CBA indicates that Component 1 is a sound economic investment that yields high benefits even in the conservative scenario. 13 Hoddinott (2003); World Bank (2006); Quisumbing, Gillespie and Haddad (2003); Alderman Hoddinott and Kinsey (2002); Ross and Horton (2003); Granthan-McGregor et a1 (2007) 14 A proportionate cost of Component 1 was used to account for excluding the benefits to women and adolescents US$1.9 million was used (76% of total cost of Component 1) 21

32 Table 9 Cost-benefit analysis of The Gambia MCNHR Project Base Scenario Stunting earnings premium of 15% Discount rate of 5% Million US$ Costs Present Value at 5% discount rate 1.5 Benefits Present Value of increased lifetime earnings resulting from reduced stunting at 5% discount rate 3.0 Net Present Value (NPV) 1.5 Benefit/Cost (B/C) Ratio 2.0 Sensitivity Analysis Million US$ Scenario 2: Stunting earnings premium of 20%; Discount rate of 5% Costs Present Value at 5% discount rate 1.5 Benefits Present Value of increased lifetime earnings resulting from reduced stunting at 5% discount rate 4.0 Net Present Value (NPV) 2.5 Benefit/Cost (B/C) Ratio 2.7 Scenario 3: Stunting earnings premium of 10%; Discount rate of 5% Costs Present Value at 5% discount rate 1.5 Benefits Present Value of increased lifetime earnings resulting from reduced stunting at 5% discount rate 2.0 Net Present Value (NPV) 0.5 Benefit/Cost (B/C) Ratio Components 2 and 3 comprise the health-systems strengthening aspect of the Project. The cost effectiveness and return on investment for Components 2 and 3 were analyzed based on core interventions that will be introduced under these components. The bulk of the resources under these components will go to health facilities under performance-based contracts for the delivery of packages of health services and for the management and TA necessary to enable them to deliver the services. The MBB analysis outlines the cumulative effect of per capita investments in prioritized interventions. Extrapolation from the broader analysis allows conclusions to be drawn regarding the economic benefits of the project on key prioritized interventions noted in the government s Health Sector Investment Case. 68. The Investment Scenario requires that in order to reduce under-five and maternal mortality by percent and percent, respectively, an additional investment of US$2.71 per capita per year is required on average. It requires only one-thirteenth additional per capita of the current total health expenditure of US$26 per capita. The conclusion is that the benefits from the US$1.95 per capita per year investment from the project (over 5 years to men, women and children) significantly outweigh the costs of retaining the status quo. As presented in Table 11, the project investments from Components 2 and 3 can be expected to bring about reductions in child and maternal mortality by 12.3 percent and 7.5 percent, respectively. In addition, coupled with the demand-side interventions of Component 1, the health and nutrition improvements gained through the Component 2 and 3 investments will be further amplified. 22

33 Table 10 Estimated child and maternal mortality reduction by Component 2 and 3 Component 2 and 3 Investment Scenario Reduction in under 5 mortality rate (U5MR) 12.3% Reduction in maternal mortality rate (MMR) 7.5% Cost per capita per year US$1.95 B. Technical 69. The government proposal builds on the global consensus of the importance of community nutrition programs as articulated in the Bank s strategy document Repositioning Nutrition as Central to Development (2006) and Scaling up Nutrition: What does it cost (2010). A recent cross-country review of successful programs has indeed shown that malnutrition can be reduced two to four times faster than in the absence of such a program. 15 The main thrust of communitybased nutrition and health programs is education and counseling regarding mother and child care practices, and links to essential health services. 70. A range of international examples of cash transfer programmes in diverse regions of the world, from Latin America to Africa, have shown their positive results on poverty reduction and, when targeted at children, on child poverty reduction. 16 Further, empirical evidence for Senegal using national household data presented in this section shows that a cash transfer programme could have a positive impact on the reduction of child poverty. Senegal has made progress in recent years in the supply of basic services, although there are still significant challenges in access to quality services, particularly in rural areas, where there are significant differentials in access with respect to urban areas, and where most of the poor live. A cash transfer program to poor households with children could be a helpful mechanism to strengthen uptake of services, so complementarities can be strengthened. 71. Furthermore, global evidence on CCT programs that transfer cash on the condition that those households make pre-specified investments in human capital shows that in addition to reducing consumption poverty, the CCTs have been successful in substantially increasing utilization of health and education services. 17 CCTs have also contributed to reductions in preexisting disparities in access to services. However, the evidence is mixed on the impact of CCTs on final outcomes (e.g. height-for-age, maternal mortality, etc.). Constraints at the household level beyond the reach of the CCT and low quality of services largely explain the muted impact on final outcomes. However, the supply-side interventions in this project are expected to mitigate the supply-side constraints and the social and behavior change components are aimed at mitigating some of the household constraints. 15 Mason, JB., D. Sanders, P. Musgrove, Soekirman, R. Galloway. Community Health and Nutrition Programs in Disease Control Priorities in Developing Countries (2nd Edition),ed., 1,053-1,074. Oxford University Press, New York, Barrientos A, R. Holmes. Social Assistance in Developing Countries Database. IDS, Brighton, Fiszbein A. et al. Conditional Cash Transfers: Reducing Present and Future Poverty IBRD: Washington, DC. 23

34 C. Financial Management 72. A Financial Management (FM) assessment of the National Nutrition Agency (NaNA), responsible agency of the FM activities of the Maternal and Child Nutrition and Health Results Project (MCNHRP), was carried out in December The FM assessment was conducted in accordance with the Financial Management Practices Manual issued by the Financial Management Board on March 1, The conclusion of the FM assessment is that NaNA s financial management arrangements meet the Bank s minimum requirements under OP/BP The residual risk rating for NaNA is Moderate. Details on the Financial Management arrangements for this project are included under Annex 3. For the implementation of the MCNHRP, NaNA should (i) recruit an external auditor by six (6) months after effectiveness and (ii) roll out the Gambian Integrated Financial Management Information System (GIFMIS) at NaNA, by fifteen (15) months after the effectiveness date. The project team will use the existing financial management accounting software before the GIFMIS become operational. D. Procurement 74. The proposed project will have the following management setup: NaNA will be the fund holder while MOHSW and RHT will act as the regulators. Accordingly, NaNA will be responsible of all procurement activities. Procurement activities for the proposed project will be conducted using the existing institutional arrangements for the implementation of the preceding Rapid Response Nutrition Security Improvement Project (P121509). NaNA is overseen by the Agency Board and receives its political support from the National Nutrition Council chaired by the Vice President. NaNA is currently sufficiently staffed in the Procurement Section. In addition, the Agency has a Project Coordinator, a Financial Management Specialist, an Accountant and a Monitoring and Evaluation Specialist. 75. The project management team is familiar with IDA procedures and has handled procurement under the previous IDA project as well as for other donor-supported operations. NaNA has performed satisfactorily over the past five years. This experience and the expertise that has developed in NaNA is expected to greatly benefit the arrangement of the new project and will help mitigate the residual risks that are: i) the need to update the manual of procedures to take into account the proposed project; ii) the need of training the staff to update their knowledge in The World Bank procedures; and iii) the need of space to organize the filing system of the proposed project. The risk is considered Moderate and is expected to be low once the following mitigation measures are implemented: i) the procedure manual updated taking into account the activities of the proposed project; ii) staff trained in World Bank procedures; and iii) adequate office space identified to organize and secure procurement files inter alia. 76. The following guidelines apply to the project: (i) Guidelines on Preventing and Combating Fraud and Corruption in Projects Financed by IBRD Loans and IDA Credits and Grants, dated October 15, 2006 and revised in January 2011; (ii) Guidelines: Selection and Employment of Consultants under IBRD Loans and IDA Credits ant Grants by World Bank Borrowers published by the Bank in January 2011; and (iii) Guidelines : Procurement of 24

35 Goods, Works and Non-consulting Services under IBRD Loans and IDA Credits and Grants by World Bank Borrowers published by the Bank in January E. Social (including Safeguards) 77. The project is expected to have a positive social impact by empowering household and communities to improve the health and nutritional status of women and children and by improving accessibility of health care for the poorest households. Component 1 is in large part dedicated to subsidize social and behavior change as well as demand for health care services. Considering the importance of social and cultural beliefs and practices that influence maternal and child care, and eventually nutrition and health outcomes, the project will pay particular attention to a communication strategy; existing communication strategies will be reviewed and the updated and new strategies will be pilot tested. Also, culture sensitive information and communication strategies will be developed and used for the community based health and nutrition services. The culture sensitive information will include beliefs surrounding early ANC registration, family planning, initiation of breastfeeding and implication of these for the health of mother and baby. 78. The project will also enhance community ownership through their involvement in achieving community targets and monitoring the quality of community nutrition interventions and basic health services. The preparation process of the project was highly participatory with extensive work and consultation among the key stakeholders including selected line ministry representatives and the key development partners. The monitoring and evaluation system has been designed to ensure adequate targeting of project activities, including social impacts. It is envisioned that this will improve understanding of women s role in health and eventually their status. To that effect, the client will undertake gender study focusing on the role of women in food production and security, consumption, and reproduction. F. Environment (including Safeguards) 79. The project triggers the Environmental assessment policy OP4.01 due to the potential for medical waste generation and the need for proper management and disposal of this waste. The institutions to be involved in the implementation of this project have the capacity to deal with the rather manageable medical waste expected from the facilities to be supported under the project. The Health Care Waste Management Plan (HCWMP) has been developed and disclosed incountry on January 30, 2014, and at the Info-shop on January 22, The project design incorporates the safe and responsible handling and disposal of medical waste through several measures. Additionally, the quality verification tool, a supervision checklist that will be administered on a quarterly basis, includes verification of medical waste measures by the facility. Indicators of medical waste handling will therefore be monitored in every facility on a regular basis. Poor performance on the facility quality tool score impacts the level of payment a service provider facility will receive, so facilities that perform better on waste management practices receive higher payments. This will act as an incentive to health workers to adopt good waste management practices and ensure staff adheres to the guidelines. The project management team and the RHTs play an important role in monitoring this aspect of the program. The World Bank safeguard specialist on the team will provide additional guidance as required. 25

36 .. Annex 1: Results Framework and Monitoring THE GAMBIA: Maternal and Child Nutrition and Health Results Project (P143650) Project Development Objectives PDO Statement Proposed Development Objective: to increase the utilization of community nutrition and primary maternal and child health services in selected regions in the Recipient s territory These results are at Project Level Project Development Objective Indicators Cumulative Target Values Data Source/ Responsibility for Indicator Name Core Unit of Measure Baseline YR1 YR2 YR3 YR4 End Target Frequency Methodology Data Collection Children 0-6 months exclusively breastfed Deliveries attended by certified midwives in the preceding year Children between the age of 6 and 59 months receiving Vitamin A supplementation Percentage Every two years Survey NaNA, MOHSW Number 8,885 9,000 9,800 11,000 12,800 15,000 Yearly HMIS MOHSW Number 0 70, , , , ,000 Quarterly HMIS MOHSW Women using modern methods of family planning 2 Number ,000 13,500 14,250 15,500 17,000 Yearly HMIS MOHSW Direct project beneficiaries Number 0 100, , , , ,000 Yearly Female beneficiaries Percentage Sub-Type Supplemental HMIS, Community Registers MOHSW, NaNA 26

37 Intermediate Results Indicators Cumulative Target Values Data Source/ Responsibility for Indicator Name Core Unit of Measure Baseline YR1 YR2 YR3 YR4 End Target Frequency Methodology Data Collection Component 1: Community mobilization for social and behavior change Pregnant women referred by VSG members for delivery and complication management Hand washing stations/points established Community registers updated quarterly Pregnant/lactating women, adolescent girls and/or children under age five-reached by basic nutrition services (number) Children between the age of 6 and 59 months receiving Vitamin A supplementation (number) Pregnant women receiving iron and folic acid (IFA) supplements (number) Children under the age of 24 months benefiting from improved infant and young child feeding (IYCF) practices (number) Children under age five treated for moderate or severe acute malnutrition (number) Number 0 1,000 3,000 5,000 7,500 10,000 Yearly HMIS MOHSW Number ,250 2,500 4,000 Quarterly Number Quarterly Number 90,000 90, , , , ,000 Yearly Number Sub-Type Breakdown Number Sub-Type Breakdown Number Sub-Type Breakdown Number Sub-Type Breakdown 70,000 70, , , , ,000 9,000 9,000 10,000 11,000 13,000 15,000 10,000 11,000 30,000 49,000 66,000 80, ,000 2,000 3,000 4,000 VSG, CHN, RHT, CLTS Community Health Nurse HMIS, Community Register Community Led Total Sanitation NaNA MOHSW, NaNA 1 Baseline is the national figure from the DHS These are quarterly totals which include double counting of women using short term methods. The assumption is that the method mix will not change as a result of the project. Trends will be monitored and action will be taken if assumption proves to be wrong. 27

38 . Indicator Description Project Development Objective Indicators Indicator Name Children 0-6 months exclusively breastfed Deliveries attended by certified midwives in the preceding year Children between the age of 6 and 59 months receiving Vitamin A supplementation Women using modern methods of family planning Direct project beneficiaries Female beneficiaries Intermediate Results Indicators Indicator Name Component 1: Community mobilization for social and behavior change Pregnant women referred by VSG members for delivery and complication management Hand washing stations/points established Community registers updated quarterly Pregnant/lactating women, adolescent girls and/or children under age five-reached by basic nutrition services (number) Description (indicator definition etc.) Proportion of infants up to 6 months who are fed exclusively with breast milk in selected regions Number of deliveries attended by certified midwives in the past year in selected regions Cumulative number of children 6-59 months who have received a vitamin A supplement Number of women who are using any modern method of contraception in the past year in selected regions Direct beneficiaries are people or groups who directly derive benefits from an intervention (i.e., children who benefit from an immunization program; families that have a new piped water connection). Please note that this indicator requires supplemental information. Supplemental Value: Female beneficiaries (percentage). Based on the assessment and definition of direct project beneficiaries, specify what proportion of the direct project beneficiaries are female. This indicator is calculated as a percentage. Based on the assessment and definition of direct project beneficiaries, specify what percentage of the beneficiaries are female. Description (indicator definition etc.) Number of pregnant women referred by VSG members for delivery and management of pregnancy or delivery complications in the past year in selected regions Number of hand washing points established according to minimum criteria in selected regions Number of community registers correctly updated This indicator includes total beneficiaries reached by any of the following services: direct feeding programs; programs promoting appropriate infant and young child feeding; nutrition programs for adolescent girls; provision of micronutrient supplements to pregnant/lactating women and children under five; food fortification; deworming; monitoring of nutritional status; nutrition and food hygiene education; nutrition components of early childhood development programs, home gardens and small livestock production for improved dietary diversity; targeted emergency food aid and treatment of severe acute and moderate acute malnutrition. 28

39 Children between the age of 6 and 59 months receiving Vitamin A supplementation (number) Pregnant women receiving iron and folic acid (IFA) supplements (number) Children under the age of 24 months benefiting from improved infant and young child feeding (IYCF) practices (number) Children under age five treated for moderate or severe acute malnutrition (number) Component 2: Delivery of selected PHC services Children dewormed in the preceding year Pregnant women coming for ANC in the first trimester in the preceding year Post-partum mothers supplemented with VAS in the preceding year Component 3: Capacity building for service delivery and results-based financing Health workers (including central and regional level managers) trained on RBF management RBF adopted in the revised health financing policy Health personnel receiving training (number) This indicator includes total beneficiaries reached by any of the following services: direct feeding programs; programs promoting appropriate infant and young child feeding; nutrition programs for adolescent girls; provision of micronutrient supplements to pregnant/lactating women and children under five; food fortification; deworming; monitoring of nutritional status; nutrition and food hygiene education; nutrition components of early childhood development programs, home gardens and small livestock production for improved dietary diversity; targeted emergency food aid and treatment of severe acute and moderate acute malnutrition. This indicator measures the cumulative number of pregnant women receiving IFA supplements through a Banksupported point of service contact (for example, during antenatal care services) or with Bank-funded IFA commodities distributed in a Bank-funded or non-bank funded program over a 12 month period. This indicator measures the cumulative number of pregnant women receiving IFA supplements through a Banksupported point of service contact (for example, during antenatal care services) or with Bank-funded IFA commodities distributed in a Bank-funded or non-bank funded program over a 12 month period. This indicator measures the number of children under age five receiving treatment, for moderate acute malnutrition (MAM) or severe acute malnutrition (SAM) through Bank-supported programs and/or with Bankpurchased commodities over a 12 month period. Number of children who received deworming treatment in the past year in selected regions Number of pregnant women coming for ANC within 1st trim of pregnancy in the past year in selected regions Number of post-partum mothers receiving VAS within 8 weeks of delivery in the past year in selected regions Number of health workers trained in RBF management Adoption by MOHSW of RBF in health financing policy This indicator measures the cumulative number of health personnel receiving training through a Bank-financed project. 29

40 Annex 2: Detailed Project Description THE GAMBIA: Maternal and Child Nutrition and Health Results Project 1. This project will prioritize selected interventions directly linked to the reduction of maternal and child under-nutrition, morbidity and mortality. Interventions will focus on strengthening community structures and the PHC system to enhance the quality and quantity of services by empowering individual women, communities (including community groups) and front line health workers to improve uptake, participation, ownership, caring practices and accountability for maternal and child health and nutrition. This project will support activities aimed at improving service delivery as well as knowledge and behaviors to ensure that the knowledge and skills needed for improved maternal and child health and nutrition are available and utilized. Innovative aspects of this project include the combined use of RBF approaches on the demand- and supply-sides and at the community and PHC levels to improve health and nutrition outcomes. The project will build a culture of focusing on results by VDCs and health providers while at the same time reducing financial burden to accessing care by women and children. The project will contribute to improved health care seeking and nutritional behaviors in regions with low performing health and nutrition indicators. 2. The proposed project envisages three complementary components: (i) facilitating community mobilization for social and behavior change; (ii) enhancing delivery strengthening of selected PHC services; and (iii) building capacity for service delivery and RBF. As such, components 1 and 2 will apply RBF mechanisms to address demand- and supply-side challenges as well as social and behavioral change for the improvement of maternal and child health and nutrition outcomes, respectively. Component 3 will strengthen overall management capacity (including monitoring and evaluation) of communities, local government and the health system to effectively engage in results-based management. The roll-out of supply-side and demand-side interventions will be geographically coordinated to ensure operational costs and subsidy payments are kept within reason. Table 2.1 shows a summary of activities by component. Table 2.1 Summary of activities by component Component 1: Community mobilization for social and behavior change Component 2: Delivery of selected PHC services Component 3: Capacity building for service delivery and RBF Conditional cash transfers to communities and support groups Conditional cash transfer to individuals Social and behavior change communication (SBCC) Performance-based financing for health centers Startup support (including selected health care waste management measures) Capacity building M&E, operational research and verification Coordination and program management at national and decentralized levels Performance contracts with RHTs, RBF Committee, HMIS and NaNA 3. Component 1: Community mobilization for social and behavior change: This component will focus on community-based promotion of key family practices (i.e., the 12 family 30

41 and community practices that promote child survival, growth and development) 18 and health care seeking behaviors for improved maternal and child health and nutrition outcomes through: i. Provision of conditional cash transfers to communities and village support groups (VSG) to increase demand for health and nutrition services through counseling and timely referrals for life-saving health services (e.g., hygiene, sanitation, counseling on infant and young child feeding, delayed first pregnancy and child spacing, referral of pregnant women and children with danger signs to health centers); ii. Provision of conditional cash transfer (CCT) to individual women to increase utilization of timely antenatal care; iii. Accompanying measures aimed at promoting behavioral changes and increasing demand to improve household practices related to health and nutrition through social and behavior change communication (SBCC; which includes technical advisory services and training). 4. For intervention (i), VDCs will sign an RBF contract with the RHT. Payments will be quarterly and/or six-monthly for achieved performance on predefined indicators. NaNA will verify the achievement of results and Community-Based Organizations (CBO) will counterverify a sample of these results through patient-tracing and client satisfaction surveys. The list of incentivized indicators defined by consensus by NaNA and the MOHSW focus primarily on maternal and child health and nutrition. Achievement of SBCC targets will be verified through reliability assessment of routine monitoring reports and community surveys. In addition, equity criteria will be developed to reward geographically remote communities with larger payment amounts to compensate for the additional cost of mobilizing communities and delivering services. Remoteness criteria will be outlined in the next version of the Project Operations Manual (POM) once the pricing assessment report has been finalized. 5. DCs can use their payments for operating costs, community mobilization and performance-based incentives to individual members of the Village Support Groups (VSG) 19. VDCs, which act on behalf of their communities, can use the cash for community development activities to attain results and benefit the wellbeing of women and children, according to the Financing Instructions and General Orders by the Government. Altogether, this component will finance results, training and workshops, communication, material and equipment (i.e., startup costs) and operating costs. 6. In intervention (ii), CCTs will be provided to women for completing their first ANC visit during the first trimester and following through with at least three more scheduled ANC visits in the course of pregnancy. Use of the services will be verified by NaNA using health center records. Once the data has been verified, payments will be transferred to women by the health centers where the services were provided. 7. Intervention (iii) will focus on SBCC strategies implemented to accompany the other subcomponents in order to have a comprehensive and sustainable approach to promoting behavioral 18 Hill Z., Kirkwood B.R., Edmond K. Family and community practices that promote child survival, growth and development: A review of the evidence. WHO, Geneva (2004). 19 VSGs are composed of male and female members of the community (including Traditional Birth Attendants) who have supported implementation of the nutrition program at the community level, particularly the BFCI. 31

42 changes and increasing demand for health care utilization. All three sub-components combined are expected to improve household practices and treatment-seeking behaviors related to health and nutrition. 8. Component 2: Delivery of selected primary health care services: This component aims to support the delivery of selected nutrition and health care services at primary, and, where needed, referral health care levels, through: (i) provision of performance-based grant to health centers for the delivery of a predefined package of maternal and child health and nutrition services at primary and referral health care facilities; and (ii) provision of startup support for effective service delivery, including the implementation of selected health care waste management measures. 9. In intervention (i), a fee-for-services mechanism which includes quantity and quality payments for a defined package of maternal and child health and nutrition services will be introduced. Payment will be triggered following quantity verification by NaNA. The final amount will be determined following quality verification by RHTs. Health centers will sign an RBF contract with the MOHSW RBF Committee and receive quarterly payments corresponding to their achieved performance based on both the quantity and quality of services delivered. The demand side financial barrier to access services will be reduced by eliminating the practice of requiring patients to pay user fees for the agreed package of services in public and not-for profit health facilities contracted under the project. 10. The list of selected indicative RBF indicators by type of RBF is shown in Table 2.2. These indicators will be updated based on burden of disease, public health and nutrition priorities of the MOHSW and NaNA and emerging evidence and experience from the implementation of the project. Much attention will be paid to ensuring the sustainability of results and the modalities and mechanisms are described in further detail in the ensuing paragraphs. Table 2.2 Indicative list of selected RBF indicators by Component and RBF approach Component RBF type RBF Indicators 1: Community mobilization for social and behavior change Conditional cash transfer with communities 1 Number of women registering for ANC in the first trimester, completing 3 other scheduled visits Number of women completing the minimum number of PNC visits Number of pregnant women and mothers with children under six months who can cite at least 2 advantages of exclusive breastfeeding Number of lactating mothers who can correctly describe minimum acceptable diet 2 Number of pregnant women being referred, evacuated and escorted by the TBA/VSG member to health facilities for delivery and medical attention Number of households with latrines (as defined in POM) Number of communities practicing environmental hygiene criteria (as defined in operations manual) Community Registers being correctly updated and summaries submitted to the RHT Quality check list for BFCI criteria administered quarterly in line with the operations manual 32

43 2: Delivery of selected PHC services Conditional cash transfer with women 3 Performancebased payments to service providers (quantity and quality) Pregnant women coming for ANC in first trimester and following through with at least three more ANC visits in the course of pregnancy Primary care level indicators: Number of women having received ANC in the 1 st trimester Number of women having received 3 additional ANC with quality check list (focused ANC) Number of pregnant women delivering with skilled attendance Number of post-partum mothers being provided with a minimum of 3 PNC services within 6 weeks of delivery Number of referrals of women with pre-, intra- and post-partum complications Number of women and adolescent girls supplied with modern methods of family planning (method-specific pricing) Number of children 6-59 months administered VAS according to protocol Number of children dewormed according to protocol Number of children referred for neonatal complications Number of children with SAM on treatment according to protocol Quality check list for service delivery administered quarterly in line with the operations manual Secondary level indicators: Number of pregnancies with complications before and during delivery requiring interventions Number of mothers treated for postpartum complications Number of infants treated for neonatal complications Number of people provided with a permanent family planning method (tubal ligations, vasectomy) 1 Some of the indicators are base indicators; others will be phased in and out 2 Proportion of children 6 23 months of age who receive a minimum acceptable diet (apart from breast milk) is calculated from the following two fractions: Breastfed children 6 23 months of age who had at least the minimum dietary diversity and the minimum meal frequency during the previous day 3 Scaling up will be decided after completion and review of the pre-pilot 11. The fee schedule takes into consideration: (i) the reasonable unit-cost of delivery the particular package of services; (ii) current coverage of interventions; (iii) disease burden and cost of accessing each of the prioritized services by users; (iv) interventions most prioritized by the MOHSW and NaNA; (v) labor intensity of each public health intervention; and (vi) whether the service will benefit from a parallel demand side incentive. 12. Challenges faced by facilities in remote areas result in higher costs to deliver services. The fee for service scheme will also take this into account by adjusting the fees upwards for the delivery of services in more remote areas. 20 A hardship factor will be integrated into the design of fee schedules and will be endorsed by the Project Steering Committee. The amount to be paid to individual health facilities under the service delivery contracts will be calculated as follows and is illustrated in Table 2.3: Objective remoteness criteria will be outlined in the next version of the Project Operations Manual (POM) once the pricing assessment report has been finalized. 21 A detailed pricing exercise was undertaken and the final fee schedule for RBF services will be updated in the POM once the report has been finalized. The fee schedule will be updated in line with intervals set in the POM. 33

44 Step 1: Number of services for each indicator multiplied by the fee for each indicator = payment per indicator Step 2: Total of all payments for all indicators multiplied by the facility quality score (maximum 100 percent) = total RBF payment per facility. The facility quality score includes 70 percent for technical quality assessed by RHTs and 30 percent patient satisfaction score. The quality score will be given a 50 percent weight factor; i.e. facilities will receive a quality bonus equal to half of the quality score. Step 3: Facilities entitled to a hardship bonus will receive an additional 15 percent on average on top of the amount calculated in step Table 2.3 Example of RBF Payment Calculation Indicator Unit Price (US$) Units (number) Payment (US$) Women referred for pre-, intra- and post-partum complications Pregnant women completing 4 visits of antenatal care in line with quality protocol Antenatal care within the first trimester ,00 Pregnant women delivering with skilled attendance Female users of modern family planning methods Children 6-59 months administered vitamin A supplements Children months dewormed according to protocol Postpartum women completing 3 postnatal care visits within 6 weeks Children referred for neonatal complications Subtotal RBF payment (I) 1, Quality score (technical score + client satisfaction) Subtotal RBF payment (II) 1, Hardship bonus 15% Total RBF payment to facility 2, Health centers can be Government-run or private (not-for-profit). NaNA will verify the achievement of quantity outputs. A quality assessment tool will be used by RHTs to assess the quality of services provided by the contracted health facilities each quarter. The tool has a broad variety of indicators such as cleanliness, quality of recordkeeping, availability of staff and supplies etc. In addition to the assessment of quality by RHTs, CBOs will be contracted by NaNA to undertake client tracer and satisfaction surveys with a view to: (i) verify the 22 This reflects the fact that the cost of delivering a service in a rural area is higher than delivering the same service in an urban area. 34

45 authenticity of patients and services reported by a health facility; and (ii) capture patient feedback regarding the services they received. While performance-based payments to the health centers are made on selected indicators, RHTs will also monitor the adequate delivery of nonincentivized services. Penalties will be applied in the event of incomplete reports on nonincentivized services or disproportionate bias towards the delivery of incentivized services. 14. Health centers can use their RBF payments for material and equipment, training, consulting services and operating costs, and staff bonuses that will ultimately improve service delivery. This component supports autonomy, social entrepreneurship and local level planning at health facility and community levels. Health providers will invest RBF payments to improve service delivery, motivate staff and develop innovative ways to attract more patients. Facilities will have sufficient decision space for social entrepreneurship to use the performance payments to improve the demand and quality of services provided and this will be clearly stated in performance contracts. As part of the RBF contracting cycle, each health provider will develop a business plan which serves as a guide for future investments and use of RBF payments. Business plans will be based on priority needs defined by the communities represented by Catchment Area Committee members and health workers. Based on technical support needs of health facilities, the RHT and where needed, the MOHSW RBF Committee will provide advice and support to health facilities to develop business plans. RHTs will supervise health facilities to ensure that business plans are in place at the start of each contracting cycle. 15. Through intervention (ii), the project will provide start-up support to ensure a minimum level of service provision capacity. This will include implementation of selected health care waste management measures (e.g. incinerators, open pits for burning, etc.). To address bottlenecks that lie outside the control of facilities, higher-level RBF management structures (RHTs, MOHSW RBF Committee, etc.) will be involved in developing and modifying policies that will be conducive to overcoming those bottlenecks. 16. The POM describes the key features of the PBF model including: (i) the approach to engage health facilities; (ii) the service package and fee schedule for primary care and referral level health facilities as well as the mechanism and timing for periodic updating of unit costs; (iii) the quality assessment tool; (iv) roles and responsibilities for the verification of results; and (v) penalties for misreporting, misuse of funds and other irregularities. The POM will be a living document that will be updated regularly based on lessons learnt during implementation. The first major updates to the POM will be after the review of ongoing pilot interventions which have been under implementation since November This review is scheduled for June Component 3: Capacity building for service delivery and results-based financing: This component will support: (i) strengthening the management capacity of key implementing entities including NaNA, MOFEA, MOHSW, MOHSW RBF Committee, health service providers, VDCs, VSGs, and RHTs for effective implementation of the RBF, including: (i) strengthening governance and strategic RBF management capacity; (ii) improving the Health Management Information System (HMIS); (iii) supporting community demand, organization and mobilization; (iv) social and behavior change communication strategy development; (v) institutionalization of RBF; (vi) training for RHTs on the use of 35

46 (ii) quality supervision tools and innovative ways to improve verification and supervision; and (vii) mentoring and peer learning among RBF stakeholders, all through the provision of technical advisory services, training, and the acquisition of goods; monitoring and evaluation; verification of RBF activities including cost of the IVA and CBOs; and operational research, learning and knowledge management activities through the provision of technical advisory services and training; (iii) project implementation including project management and coordination, fiduciary management, oversight, and communications, through the provision of technical advisory services, training and operating costs (iv) Ensuring effective management and implementation support of the RBF by the RHTs, HMIS, NaNA, and MOHSW RBF Committee by means of performance agreements. 18. Capacity building will be provided through: (i) long-term technical assistance; and (ii) inservice and on-the-job training and consulting services. To the extent possible, capacity building will use in-country peer learning and south-south learning from countries with mature RBF programs. This component will also strengthen the capacity of the MOHSW in RBF, procurement and financial management. Immediate capacity building priorities from the above list of activities are: (i) technical assistance, training and on-the-job learning for verification; and (ii) training for RHTs and MOHSW RBF Committee to develop and use a RBF quality supervision tool. 19. In view of the importance of HMIS in the implementation of core RBF functions, key aspects that will be prioritized in HMIS improvements include building a core team in MOHSW and NaNA that can take advantage of DHIS2 system capabilities in supporting data entry, processing and automated output reports and payment invoices which will be vital for health providers, VDCs and management structures of MOHSW and NaNA. 23 International or regional TA will be engaged to enable use of the web application programming interface (API) with emphasis on the functionality of DHIS2 to encompass RBF. Investments in strengthening HMIS will enable NaNA to establish a web based payments database which will be linked to the DHIS2 platform. Based on a rapid assessment, the MOHSW has embraced information technology and its ongoing partnership with the University of Oslo in rolling out DHIS2 provides a strong foundation for targeted technical assistance and investments in HMIS infrastructure, web connectivity, software and technical skills critical for the roll-out of the project. 20. The RBF program will be designed to enable learning through not only standard M&E systems but also operational research, documentation, knowledge management and process and impact evaluations to capture the effect, efficiency and implementation challenges of the program with respect to health and nutrition outcomes, ownership, cost-effectiveness, and other aspects of community mobilization and health system strengthening. 24 The rolling out of process evaluations will be a key feature of the project to strengthen learning from RBF implementation. 23 District Health Information System, version 2 (DHIS2) is a complex health information system for collecting, analyzing and reporting health related data. DHIS 2 is free and open source and is implemented in many developing countries and allows decentralized access to and analysis of data. 24 The impact evaluation will be Bank-executed with additional financing from MDTF-HRI. 36

47 21. Finally, performance contracts will be used to support essential RBF supervision and management functions of the RHTs, HMIS, MOHSW RBF Committee, and NaNA. Accordingly, RHTs will sign performance contracts with the MOHSW RBF Committee and receive quarterly payments corresponding to their achieved performance on key functions. Their main responsibilities will be the monitoring and supervision of health centers, quality verification of health centers and management of contracts with VDCs. Furthermore, the MOHSW RBF Committee and NaNA will sign performance contracts with the Ministry of Finance and Economic Affairs (MOFEA) and receive quarterly payments corresponding to their achieved performance on key management functions, including the RBF Committee s management of performance contracts with health facilities and RHTs, setting and ensuring minimum quality and service delivery standards; and NaNA s management of outputs payment budget, management of IVA, client tracers and LQAS contracts, and fiduciary management reporting. 22. The detailed project cost estimates are provided in Table 2.4. Table 2.4 Project cost by component, source and actions Actions Project Cost IDA Financing Component 1: Community mobilization for social and behavior change MDTF-HRI Financing % IDA Financing Conditional cash transfers to VDCs % Conditional cash transfers to women % Social and behavior change communication % Sub-total component % Component 2: Delivery of selected PHC services Performance-based financing for health centers % Start up support % Sub-total component % Component 3: Capacity building for service delivery and results-based financing Capacity building; M&E, operational research and verification; Coordination and program management at national and decentralized levels Performance contracts with RHTs, RBF Committee and NaNA % % Sub-total component % Grand total

48 Annex 3: Implementation Arrangements THE GAMBIA: Maternal and Child Nutrition and Health Results Project Project Institutional and Implementation Arrangements 1. The two principal institutions responsible for implementation are NaNA and the MOHSW. Both MOHSW and NaNA work through the RHT to oversee community mobilization and service delivery. The MOHSW and RHT RBF Committees will be the purchaser and regulator of services. NaNA will be the fund holder for the project. The RBF Committee in the MOHSW will coordinate the implementation of the various maternal and child health activities to be carried out by the different technical units (Directorates, Divisions) through the Director of Health Services. Health Centers and VDCs will be the providers of services. The institutional arrangements are shown in Figure 3.1. Figure 3.1: Project implementation arrangements Project administration mechanisms 2. As fund holder, NaNA will ensure the fiduciary management for the project, including procurement. NaNA also has a higher mandate of multisectoral coordination for improved nutrition. Accordingly, the project can be linked to developments in other sectors that influence health and nutrition outcomes such as the investments in agriculture and food security. To ensure effective coordination between the MOHSW and NaNA, a Project Implementation Committee 38

49 (PIC), composed of members from the two institutions, has been set up since the pilot learning experience. The PIC is chaired by the Project Coordinator who sits in NaNA. The PIC is responsible for the development of annual work plans and budgets, coordinate and review progress implementation of the project, conduct regular monitoring and supervision, monitor and score RHT contracts, provide implementation support, select external verification agents and client tracers including CBOs, and prepare quarterly and annual reports. Key day-to-day project implementation functions will be ensured by the Project Coordinator, the Project Facilitator, the Financial Management Specialist, the Procurement Specialist and the M&E Officer of NaNA. In addition, the Project Team is directly supported by the PHC Focal Point, RCH Specialist and the Health Economist of the Ministry of Health and Social Welfare. Project implementation will be overseen by a Steering Committee composed of MOFEA, MOHSW, NaNA, the Office of the Vice President, and the Ministry of Regional Government, Land and Traditional Rulers. Table 3.1 indicates the entities that will perform each RBF function. Table 3.1 Internal and External Verification Arrangements Function/Role Purchaser and Regulator Service provider Fund holder, Payer, Quantity Verifier Quality Verifier External Verifier Responsible Entity MOHSW, RHT (RBF Committee) Health centers, VDCs NaNA RHTs, CBOs IVA, CBOs 3. The verification of results will include an internal and an external verification and responsibilities for these will be shared among a number of responsible parties. Quantity verification will be carried out by NaNA while quality verification will be the responsibility of RHTs and CBOs. The external verification will involve the IVA and CBOs. The IVA will conduct periodic technical and financial audits. The periodicity will be higher in the first two years of project implementation (i.e., every six months) after which the external verification will be reduced to one per year. CBOs will be hired to conduct the counter verification and the community verification (see Table 3.2). Table 3.2 Internal and External Verification Arrangements Internal Verification Quantity Data Verification: NaNA Verification Teams check the quantity of services by looking at the health center registers and tally sheets, VDC reports and payment claims. A sample of health centers and communities (VDCs) undergoes quantity verification every month. In the initial phase, the verification team will strive to cover 100 percent of the facilities and communities in a quarter. However, this will be reduced to an External verification Audits: An independent verification agency (IVA) performs financial and quality audits at all operational levels from the central to the community-level (including: NaNA as fund holder; MOHSW as regulator; the RBF Committees as purchasers; and health centers and VDCs as providers, by random spot checks (a sample of health centers, VDCs and VSGs is audited externally). The independent organization will use datasets from CBO client tracer surveys for its verification purposes. The IVA will also select a small 39

50 agreed sample after two years of implementing RBF by various actors in The Gambia. Depending on project performance, this can be reduced to an agreed sample after two years of implementing RBF by various actors in The Gambia. Quality Verification (for health center contracts): MOHSW represented by RHT checks the professional (medical) quality verified by performing random spot checks to ensure adherence to set protocols and standards of care as defined by the RBF supervision checklists and general checklists used in The Gambia for health center supervision (100% of facilities undergo quality verification every quarter). 75 percent of the quality score will be based on RHT supervision for quality. sample of the patients verified by CBOs and undertake counter checks to ensure the CBOs undertook the verification processes objectively and reported accurately on patients feedback. The IVA will undertake spot checks for women beneficiaries who access demand side services. IVA s technical focus and sample size will be defined in TORs to be drafted by the Working Group and cleared by the Bank. Community Verification: CBOs will be contracted by NaNA to check the authenticity of the patients reported by providers and to evaluate patient satisfaction (a sample of patients are traced and administered a patient satisfaction survey). CBOs will work with the NaNA verification teams to compile patient tracer and satisfaction scores which will contribute to 25 percent of the aggregate quality score that health centers will receive. Financial Management, Disbursements and Procurement Financial Management 4. It was agreed with the Government of The Gambia that NaNA will be in charge of the Financial Management activities of the Maternal and Child Nutrition and Health Results Project. The objective of the assessment was to determine whether NaNA has adequate Financial Management arrangements in place to ensure that the Project funds will be used only for the purposes for which the financing was provided, with due attention to considerations of economy and efficiency. The FM assessment considers the degree to which: (i) the budgeted expenditures are realistic, prepared with due regard to relevant policies, and executed in an orderly and predictable manner; (ii) reasonable records are maintained and financial reports produced and disseminated for decision-making, management, and reporting; (iii) adequate funds are available to finance the Project; (iv) there are reasonable controls over Project funds; and (v) independent and competent audit arrangements are in place. 5. NaNA financial management system is adequate for the implementation of the Maternal and Child Nutrition and Health Results Project: NaNA implemented satisfactorily The Gambia Rapid Response Nutrition Security Improvement Project and the Pre-Pilot Learning Experience of the Maternal and Child Nutrition and Health Results Project, financed by World Bank (the Bank or Association), and has already in place a qualified staff, a computerized accounting system, and an adequate Financial & Administrative Procedures manual. Financial Management Arrangements 6. Internal control: The existing Financial and Administrative Procedures manual will be applicable, but necessary updates will be performed in order to incorporate the particularities of 40

51 the Project. A second level of control, in addition to the internal control (Quantity Data Verification and Quality Verification) will be put in place: (i) an IVA will be contracted by NaNA to perform financial activities review and quality audits at all operational levels from the central to the community-level; and (ii) CBOs will be contracted by NaNA to check the authenticity of the patients reported by providers and to evaluate patient satisfaction (a sample of patients are traced and administered a patient satisfaction survey). 7. Budgeting: NaNA s current budgeting process (i.e., preparation, approval and implementation monitoring) will be used. The annual work plan and budget shall be: (i) approved by the Project Steering Committee; and (ii) submitted for IDA s review by November 30 of each year. Disbursement 8. The project will use the transaction-based disbursement procedures, i.e., replenishment, direct payment, reimbursement, and special commitments (see Figure 3.2). Two designated accounts (DA) will be opened at the Central Bank of The Gambia: DA-A for category 3 and DA- B for categories 1 and 2. Similarly, two sub-accounts, which will supplied by the DAs, will be opened in a commercial bank to facilitate payment to beneficiaries who are far from the Greater Banjul Area. The four (4) accounts will be managed by NaNA. The two designated accounts will be held in US$. The two sub-accounts will be held in Dalasi. The designated accounts ceiling and the condition of the designated accounts replenishment are indicated in the disbursement letter. Figure 3.2: Funds Flow Chart 41

52 9. Accounting: Project accounts will be maintained on a cash basis, supported with appropriate records and procedures to track commitments and to safeguard assets. Annual financial statements will be prepared by NaNA in accordance with the Financial Reporting Act The Country Portfolio Performance Review (CPPR) on May 2, 2013 decided that all new Projects must use the GIFMIS. The Recipient informs the Bank that, technically, it will be able to roll out the GIFMIS to NaNA by fifteen (15) months after effectiveness. Before the GIFMIS becomes operational, the Project team will use the existing accounting software, which it is using for the Pre-Pilot Learning Experience of this Project. 10. Financial Reporting: NaNA would submit Interim Un-audited Financial Reports (IFRs) to the Bank on a quarterly basis. IFRs should be submitted within forty-five (45) days following the end of the calendar quarter. The IFRs will include (i) sources and uses of funds by project expenditures classification, (ii) a comparison of budgeted and actual project expenditures (commitments and disbursements) to date and for the quarter, and (iii) other documents as may be required. 11. NaNA will produce Annual Financial Statements, and these statements will comply with the Gambian law and World Bank requirements. These Financial Statements 25 will consist of: a statement of sources and uses of funds; a statement of commitments; accounting policies adopted and explanatory notes; and a management assertion that project funds have been expended for the intended purposes as specified in the relevant financing agreements. 12. Audit: The Financing Agreement will require the submission of Project Audited Financial Statements to IDA within six months after year-end. External auditor with qualification and experience satisfactory to the World Bank will be recruited to conduct an annual audit of the project s financial statements. A single opinion on the Audited Project Financial Statements in compliance with International Standards on Auditing (ISA) will be required. The external auditors will prepare a Management Letter giving observations and comments, and providing recommendations for improvements in accounting records, systems, controls and compliance with financial covenants in the Financing Agreement. Table 3.3 Auditing requirements Audit report Financial Statements Management letter Due Date End of June 25 It should be noted that the project financial statements should be all inclusive and cover all sources and uses of funds and not only those provided through IDA funding. It thus reflects all program activities, financing, and expenditures, including funds from other development partners. 42

53 Table 3.4 Financial Management Action Plan Action When By whom 1. Roll out of the GIFMIS at NaNA 15 months after effectiveness MOFEA and NaNA 2. Selection of the auditor 6 months after effectiveness NaNA Procurement 13. The proposed project will have the following management setup: NaNA will be the fund holder while MOHSW and RHT will act as the regulators. Accordingly, NaNA will be responsible of all procurement activities. Procurement activities for the proposed project will be conducted using the existing institutional arrangements for the implementation of the now closed Rapid Response Nutrition Security Improvement Project (P121509). NaNA is overseen by the Agency Board and receives its political support from the National Nutrition Council chaired by the Vice President. NaNA is currently sufficiently staffed in the Procurement Section. In addition, the Agency has a Project Coordinator, a Project Facilitator, a Financial Management Specialist, an Accountant and a Monitoring and Evaluation Specialist. 14. The project management team is familiar with IDA procedures and has handled procurement under the previous IDA project as well as for other donor-supported operations. NaNA has performed satisfactorily over the past five years. This experience and the expertise that has developed in NaNA is expected to greatly benefit the arrangement of the new project and will help mitigate the residual risks that are: i) the need to update the manual of procedures to take into account the proposed project; ii) the need of training the staff to update their knowledge in The World Bank procedures; and iii) the need of space to organize the filing system of the proposed project. The risk is considered Moderate and is expected to be low once the following mitigation measure are implemented: i) the procedure manual updated taking into account the activities of the proposed project; ii) staff trained in World Bank procedures; and iii) adequate office space identified to organize and secure procurement files inter alia. In addition NaNA will produce a procurement plan acceptable by IDA. 15. National Competitive Bidding (NCB) method: The Recipient may ensure that the following special requirements are taken into account : (i) Prospective bidders will be provided four weeks, from the date of publication of the invitation to bid or the date of availability of the bidding documents, whichever is later, for the preparation and submission of bids; (ii) Bidding documents acceptable to the Association shall be used, and shall be prepared to ensure economy, efficiency, transparency, and broad consistency with the provisions of Section I of the Procurement Guidelines; (iii) Invitation for bids will be advertised in national newspapers with wide circulation, or in the official gazette provided that it is of wide circulation, or on widely used website or electronic portal with free national and international access; (iv) Bids shall be submitted in one internal envelope; (v) Bid evaluation criteria, bidder qualifications criteria, and the contract award criteria shall be clearly specified in the bidding documents; (vi) No margin of preference shall be granted to domestic bidders; (vii) Eligible bidders, including foreign firms, shall not be excluded from the competition; (viii) The procedures will include the publication of the results of evaluation and of the contract awards; (ix) The bidding document and contract as 43

54 deemed acceptable by the Association shall include provisions stating the Bank s policy to sanction firms and individuals, found to have engaged in fraud and corruption as defined in the Procurement Guidelines; and (x) In accordance with the Procurement Guidelines, each bidding document and contract financed out of the proceeds of the Financing shall provide that bidders, suppliers and contractors, and their subcontractors, agents, personnel, consultants, services providers, or suppliers, shall permit the Association to inspect all accounts, records and other documents relating to the submission of bids and contracts performance, and to have them audited by auditors appointed by the Association. Acts intended to materially impede the exercise of the Association s inspection and audit rights provided for in the Procurement Guidelines constitute an obstructive practice as defined in the Guidelines. 16. Procurement of Works: The project will finance refurbishment of some offices and buildings. The procurement method to be used for these contracts, depending on the amount, may be NCB or shopping. No construction will be financed under this project at the benefit of the Recipient. 17. Procurement of Goods: Goods procured under this project would include Information Technology (IT) equipment, software, office equipment, office furniture, vehicles, medicinal products, anthropometric equipment, fuel, etc. Medicinal products, anthropometric equipment, etc., will be procured by ICB (UNICEF). The other contracts are with small value (IT equipment, office equipment, office furniture, motor bikes, fuel, etc.) and will be procured by NCB. The procurement will be done using Bank s SBD for all ICB and for all NCB subject to any adaptation as required. Small contracts for goods may be procured using the shopping procedures as per paragraph 3.5 of the IDA Procurement Guidelines. 18. Procurement of non-consulting services: These services may concern operating expenses such as office maintenance, equipment maintenance, and non-consulting services related to the organization of workshops. The related contracts will be at small value and they may be procured using the shopping procedures as per paragraph 3.5 of the Procurement Guidelines. 19. Selection of Consultants: Consulting services will include financial audits, technical assistance and consultants services, training and workshops; accreditation evaluation; SBCC/IEC, evaluation survey, producing and updating manuals, etc. 20. Short lists of consultants for services estimated to cost less than US$300,000 equivalent per contract may be composed entirely of national consultants in accordance with the provisions of paragraph 2.7 of the Consultant Guidelines. 21. Operating Costs: These costs may include recurrent costs of the Project: (i) operation and maintenance of vehicle, repairs, fuel and spare parts; (ii) computer maintenance, including hardware and software; (iii) communication costs and shipment costs (whenever these costs are not included in the cost of goods); (iv) office supplies; (v) rent and maintenance for office facilities; (vi) utilities and insurances; (vii) travel and per diem costs for technical staff carrying out training, supervisory and quality control activities; (viii) salaries of support staff, but excluding salaries of the Recipient s civil servants. 44

55 Procurement Implementation Arrangements 22. An assessment of the capacity of the Implementing Agency to handle procurement actions for the project was carried out by Mamadou Mansour Mbaye, Procurement Specialist STC, based in the Dakar Office and designated for the project on the side of the Bank. The assessment reviewed the organizational structure for implementing the project and the interaction between the project s staff responsible for procurement and the Agency s relevant central unit for administration and finance. 23. Most of the issues concerning the procurement component for implementation of the project have been identified and include: (i) the need to update the manual of procedures to take into account the proposed project; (ii) the need of training the staff to update their knowledge in The World Bank procedures; and (iii) the need of space to organize the filing system of the proposed project. The corrective measures which have been agreed are: (i) update the procedure manual to take into account the activities of the proposed project; (ii) train the staff in World Bank procedures; and (iii) find sufficient office space to organize and secure procurement files inter alia. In addition, the procurement documents and procurement decisions could be submitted for prior review by the procurement control body in the country; and the control that will be exercised by the country s procurement control body might help mitigate any possible interference that may occur between the NaNA procurement unit and other central and regional units for administration and finance inside the ministries and local government. 24. The overall project risk for procurement is Moderate. However, given the limited procurement activities, the residual risk will be low thanks to the mitigation measures that will be taken. 25. Procurement Plan: The Recipient has developed a Procurement Plan for project implementation for the first 18 months which provides the basis for the procurement methods. This plan was reviewed and approved by the Bank during appraisal. The procurement plan will be made available in the Project s database at the office of NaNA in Banjul and at the Bank s external website. The Procurement Plan will be updated in agreement with the Project Team annually or as required to reflect the actual project implementation needs and improvements in institutional capacity. 26. Prior review: For ICB contracts estimated to cost above US$3,000,000 per contract and for works, US$300,000 per contract for goods and non-consulting services, the first contract irrespective of the cost estimate and all direct contracting will be subject to prior review. Consultancy services estimated to cost above US$200,000 per contract for firms and US$100,000 per contract for individual consultants, the first contract irrespective of the cost estimate and every single source selection of consultants (firms) for assignments will be subject to prior review by the Bank. 27. Short lists of consultants for services estimated to cost less than US$200,000 equivalent per contract may be composed entirely of national consultants in accordance with the provisions of paragraph 2.7 of the Consultant Guidelines. 45

56 28. Procurement supervision: In addition to the prior review supervision to be carried out from Bank offices, the recommendation from the capacity assessment of the Implementing Agency is that there will be supervision missions at least every six (6) months to visit the field and to carry out a post review of procurement actions during one of these missions. Environmental and Social (including safeguards) 29. The project triggers the Environmental assessment policy OP4.01 due to the potential for medical waste generation and the need for proper management and disposal of this waste. The institutions to be involved in the implementation of this project have the capacity to deal with the rather manageable medical waste expected from the facilities to be supported under the project. The HCWMP has been developed and disclosed in-country on January 30, 2014, and at the Infoshop on January 22, Table 3.5 Prior Review Threshold: (a) Goods and Works and non-consulting services: List of contract packages to be procured Procurement Method Levels Comments 1. Goods = or > US$300, Prior review 2. Works (if any) = or > US$3,000, Prior review 3 Direct Contracting All contracts Prior review (b) Consulting Assignments contracts with short-list of international firms: Selection Method Prior Review Threshold Comment 1. Selection of firms US$200, Prior review 2. Selection of individual consultants US$100, Prior review 3 Single source for firms and individual consultants All contracts Prior review 46

57 Table 3.6 Format of a procurement plan for the first 18 months of the project (a) Goods and Works and non-consulting services: List of contract packages to be procured Ref. No. Contract (Description) 01 Promotional Materials 01 Five 4-Wheel Drive Vehicles 02 Internet and Telecommuni cation 03 Computers, Laptops and Printers 04 Fuel for Project Implementati on Estimated Cost US$ Procurement Method Prequalification (yes/no) Domestic Preference (yes/no) Review by Bank (Prior / Post) Expected Bid-Opening Date Component N 1: Community mobilization for social and behavior change 80,000 NCB No No Post Component N 3: Capacity building for service delivery and RBF 220,000 NCB No No Prior ,000 Shopping No No Prior ,000 NCB No No Post ,000 Shopping No No Post Stationery 30,000 NCB No No Post Furniture 18,000 Shopping No No Post Medical Equipment and other Supplies 175,000 DC (UNICEF) No No Prior Printing 50,000 NCB No No Post Insurance Cover for Vehicles 30,000 Shopping No No Post Comments (b) Consulting Assignments contracts with short-list of international firms: Ref. No. Description of Assignment Estimated Cost (US$) Selection Method Review by Bank (Prior / Post) Expected Proposals Submission Date Component N 3: Capacity building for service delivery and RBF 01 External Verification 100,000 QCBS Prior Agent 02 Quality Verification 100,000 CQS Prior Agent (CCTSSA) 03 Financial Management 100,000 DC Prior Specialist 04 External Auditor 100,000 QCBS Prior Assistant Accountant 15,000 IC Post Field Assistants 90,000 IC Post Comments 30. The project design incorporates the safe and responsible handling and disposal of medical waste through several measures. Additionally, the quality verification tool, a supervision checklist that will be administered on a quarterly basis, includes verification of medical waste 47

58 measures by the facility. Indicators of medical waste handling will therefore be monitored in every facility on a regular basis. Poor performance on the facility quality tool score impacts the level of payment a facility service provider will receive, so facilities that perform better on waste management practices receive higher payments. This will act as an incentive to health workers to adopt good waste management practices and ensure staff adheres to the guidelines. The Project Implementation Committee, MOHSW and the Regional Health Team will play an important role in monitoring this aspect of the program. The World Bank safeguard specialist on the team will provide additional guidance when required. 31. The project is expected to have a positive social impact by empowering household and communities to improve the health and nutritional status of women and children and by improving accessibility of health care for the poorest households. Component 1 is in large part dedicated to subsidize social and behavior change as well as demand (and therefore accessibility) for health care services. Considering the importance of social and cultural beliefs and practices that influence maternal and child care, and eventually nutrition and health outcomes, the project will pay particular attention to a communication strategy; existing communication strategies will be reviewed and the updated and new strategies will be pilot tested. Also, culture sensitive information and communication strategies will be developed and used for the community based health and nutrition services. Culture sensitive information will include beliefs surrounding early initiation of breastfeeding and its implication for the health of mother and baby, and timely ANC seeking with its implication on the outcome of pregnancies. 32. The project will also enhance community ownership through their involvement in achieving community targets and monitoring the quality of community nutrition interventions and basic health services. The preparation process of the project was highly participatory with extensive work and consultation among the key stakeholders including selected line ministry representatives and the key development partners. The monitoring and evaluation system has been designed to ensure adequate targeting of project activities, including social impacts. It is envisioned that this will improve understanding of women s role in health and eventually their status. To that effect, the client will undertake gender study focusing on the role of women in food production and security, consumption, and reproduction. Monitoring & Evaluation 33. The project will include comprehensive routine monitoring system and rigorous evaluation that focus on: (i) monitoring the activities to ensure that they are implemented as planned (i.e. delivery of inputs, process and outputs); (ii) measuring the progress towards achieving the outcomes; and (iii) setting up a mechanism that will allow the use of findings from routine monitoring for corrective actions during the implementation; and (iv) measuring the impact of the program on key health and nutrition outcomes. The RBF mechanism entails intense ongoing data reporting, review and verification. Prompt and accurate self-reported and externally-verified data is a key factor to the implementation of RBF. Detailed M&E plans will be developed as an overall guidance of the project s M&E activities and includes results frameworks, routine monitoring and verification system, evaluation plan, standardized data collection instruments, key information products, strategies for dissemination and use of M&E information to improve results. 48

59 34. Routine monitoring and verification system will include a standardized mechanism for data reporting, technical verification and counter-verification, data analysis, monitoring and supervision procedures, and feedback mechanism to community. For data reporting, health facilities and community representatives (VDCs, VSGSs) will be collecting data based on the indicators to be incentivized and submit these to the RHT at regular intervals. Standardized data collection tools such as registers and transport book, referral and return forms will be developed to assist data collection tasks. NaNA and MOHSW will use these records to monitor the functionality of the system. An information flow matrix that describes in detail the responsibility of each project actor, data collection tools, planned use of data and timeframe and delivery schedule will be developed. 35. Thorough internal and external verification arrangements will be put in place, including internal quantity and quality verification undertaken by NaNA and RHTs, external financial and quality audits undertaken by IVA and CBOs, and beneficiaries satisfaction verification undertaken by CBOs. A key investment of the project will be to build a culture of internal reviews at various levels of the project implementation structure. Evidence from countries with advanced RBF projects show that internal reviews amongst health providers and their supervisors has greater benefits as it enables internal peer learning and joint planning to improve performance. Internal reviews of data also serve as a form of peer pressure amongst contracted health providers and VSGs as performance data will be shared widely across a region. To enable this, performance contracts for the RHT will include indicators on performance data review and on data use. Indicators on timely transmission of data from various levels will be included in relevant performance contracts and enforced through rewards or sanctions. Analysis of patient satisfaction data and feedback from the external verification reports will be used to institute midcourse improvements or adjustments to operational processes. 36. For monitoring and supervision, health facility and community monitoring checklists will be developed for use by the RHT to monitor the implementation of the project, including health care waste management. Supervision will be carried out on a regular basis by the RHT and PIC. The emphasis will be on using the monitoring and supervision findings to improve quality of implementation and to inform community and beneficiaries on the progress of the project. 37. A community nutrition data information system will be set up, emphasizing the synergies with the existing data information system and tools, e.g. HMIS, Community Registers, and the Nutrition Data Base as part of the RBF management. In some instances, special forms may need to be developed, notably for those indicators that are purchased at the community level. The project will make modest investments in collaboration with other development partners to strengthen the functionality and capacity of the HMIS team and NaNA to use DHIS2 software for data management and analysis. To the extent possible, the payment data system will be linked to the existing DHIS2 system, subject to a technical assessment. 38. The comprehensive evaluation plan will include both process and impact evaluations using various methods as necessary. It aims to enable a learning process that will capture the effect and efficiency of the program on health and nutrition outcomes, ownership, costeffectiveness, and other aspects of community mobilization and health system strengthening. 49

60 Both quantitative and qualitative approaches will be utilized, and periodic process evaluations will be a key feature of the project to strengthen learning from RBF implementation to determine now only whether implementation is working but also how it is progressing. 39. The (mixed method) impact evaluation will be prospective, randomized and controlled to allow for measuring impact attributable to the interventions. The intervention and control areas will be selected using certain criteria, e.g. access to health services, existing health and nutrition status. The impact evaluation will likely focus on the impact of the demand-side incentives to communities in addition to the supply-side incentives to facilities. Accordingly, the following arms are being considered; (i) control communities not implementing any interventions; (ii) communities implementing only supply-side interventions; and (iii) communities implementing supply-side and community-level (demand-side) interventions. If, following the findings from the pilot, the CCTs to individual women are included, and then this will be an additional arm to measure whether there is an additional impact on ANC above and beyond the supply-side and community-level interventions. 40. The process evaluation, to be conducted during project implementation, will address different operational features in terms of effectiveness and efficiency. Specifically, it will gather information on the delivery and design of the different components of the program; identify bottlenecks or constraints and possible solutions to improve implementation of the program; and explore the perceptions of different stakeholders about the effectiveness and quality of services provided and their roles and responsibilities within the project structure. The process evaluation will provide insights on organizational and behavioral changes as well as how quality of implementation affects the achievement of results indicators. 50

61 . Project Stakeholder Risks Annex 4: Operational Risk Assessment Framework (ORAF) THE GAMBIA: Maternal and Child Nutrition and Health Results Project (P143650) Stakeholder Risk Rating Moderate Risk Description: Different beneficiaries (including village support groups, community health nurses, and local and Regional health teams) may view the new approach as threatening or problematic. Because of the community mobilization component, the project will involve other Government institutions, which may not be interested to participate in the project. Engaging with the development partners to implement the project carries low risk as they have track records in working together in the past. Risk Management: The project is designed in a participatory way to ensure that feedback from all beneficiaries is integrated into the assessments and project components. In addition, the approach will be amply explained and communicated to all beneficiaries Resp: Status: Stage: Recurrent: Due Date: Frequency: Both In Progress Both Continous Risk Management: Implementing Agency (IA) Risks (including Fiduciary Risks) Capacity Rating Moderate Risk Description: The two agencies involved may be unable to adequately execute the project due to limited capacity in fiduciary and project management. A series of consultations will continue to take place between NaNA, MOHSW, development partners, the Ministry of Local Government and Lands (MOLGL), the Ministry of Finance and Economic Affairs (MOFEA), CSOs and the Vice-President's Office. Resp: Status: Stage: Recurrent: Due Date: Frequency: Both In Progress Both Continuous Risk Management: The implementation structure will take advantage of the capacity that was built by the Rapid Response Nutrition Security Improvement Project (NaNA), the GAVI and GFATM (MOHSW). The two agencies are closely collaborating on the implementation of a pilot learning experience with RBF. In addition, as needed, TA will be provided under the project to provide the necessary training to project staff. Resp: Status: Stage: Recurrent: Due Date: Frequency: Both In Progress Both Continuous 51

62 Governance Rating Substantial Risk Description: Frequent turnover in the leadership and management of the MOHSW has led to unsteady direction of the health agenda in The Gambia. Project Risks Risk Management: The project team is well engaged with key level staff in MOHSW and will continue to supervise and monitor the situation. NaNA will continue to handle the fiduciary aspects. A Project Implementation Committee composed of the MOHSW, NaNA and MOFEA has been in place since early MOHSW is fully on board. And the Vice President has given her full backing to the new project. Resp: Status: Stage: Recurrent: Due Date: Frequency: Both In Progress Both Continuous Risk Management: Design Rating Substantial Risk Description: Applying results-based financing is a new approach that the client is unfamiliar with. In addition, the project will have an added complexity combining supply- side incentives such as performance-based contracts and financing, and demand-side incentives such as community awards. This approach requires strong data evidence which is currently not available. The project team will continue their close supervision and also provide TA for strengthening fiduciary systems of the project. In collaboration with the Ministry of Finance, the Anti-Corruption Board, and the development partners, the performance of both the NaNA and the MOHSW will be a priority matter. Robust internal and counter verification mechanisms involving close monitoring and the use of an independent verification agent will be put in place. Moreover, process evaluations, a key feature of the project, will provide information on efficiency and social accountability instruments to assure transparency and client assessments of performance will be considered. Resp: Status: Stage: Recurrent: Due Date: Frequency: Both In Progress Both Continuous Risk Management: The two Implementing Entities have gathered extensive information including study tours to strengthen the understanding of RBF mechanisms. Investments in training and on-the-job coaching in RBF mechanisms will be prioritized in the implementation plan. A pilot experience in one Region will inform the preparation process. Technical assistance will be mobilized to help the Implementing Entities. Resp: Status: Stage: Recurrent: Due Date: Frequency: Both In Progress Both Continuous 52

63 Social and Environmental Rating Low Risk Description: The proposed activities are not expected to entail major safeguard issues. The management and disposal of medical waste is associated with primary health care services. Risk Management: A safeguards specialist will be part of the task team to ensure compliance with the Bank s safeguard policies. Resp: Status: Stage: Recurrent: Due Date: Frequency: Bank Completed Preparation 30-Jan-2014 Social resistance is not expected with the exception of the integration of family planning. Risk Management: A case study is currently conducted on the integration of family planning in community nutrition and primary health care. Results found no resistance but plenty of ignorance. There is adequate political support for the promotion of delayed first pregnancy and child spacing. Resp: Status: Stage: Recurrent: Due Date: Frequency: Both Completed Preparation 31-Jul-2013 Program and Donor Rating Low Risk Description: The principal donors and development partners contributing to the nutrition and health sectors include the GAVI, GFATM, UNICEF and UNFPA. GAVI and GFATM are expected to overlap with the current proposed project. The team already works closely with UNICEF and UNFPA. Risk Management: The team has extensively engaged in the sector and ensures that there is complementarity and synergies with other donor activities. The project appears to be well aligned with renewed commitments by UNFPA and UNICEF. Resp: Status: Stage: Recurrent: Due Date: Frequency: Bank In Progress Both Continuous 53

64 Delivery Monitoring and Sustainability Rating Risk Description: Monitoring: Several issues related to data collection, verification and usage pose substantial risk to the project achieving its PDO: (i) the community-based monitoring, the PHC monitoring, and the HMIS are not yet fully aligned; (ii) the temptation to inflate results and the need for reliable verification and counter-verification of results; (iii) the increasing workload that comes with monitoring and reporting; and (iv) limited capacity in monitoring and reporting at the local level (illiteracy is a major problem in the villages). Sustainability: With resources going to communities and front line health workers, there are obvious concerns about the financial sustainability of the project. Overall Risk Risk Management: Moderate The project includes a technical assistance component which will provide support specifically on the monitoring issues. The client has built capacity in community-based monitoring through the Rapid Response Nutrition Security Improvement Project. Moreover, a pilot experience has started to inform the design of the final project. Resp: Status: Stage: Recurrent: Due Date: Frequency: Both In Progress Both Continuous Risk Management: Overall Implementation Risk: Rating Substantial Risk Description: The design will pay due attention to the sustainability issues by building in measures of ownership at community and national levels. These measures will build on the existing approaches and structures under PHC and BFCI. At the national level, MOFEA will be directly involved with MOHSW and NaNA through the steering committee. The preparation of the design of the project will keep the issue of financial sustainability central. The annual cost for scaling up at national level the RBF mechanism will only be a fraction of the existing Government health budget. The design and financial implications will be closely reviewed with the involvement of the Office of the Vice President, MOFEA and MOHSW. Resp: Status: Stage: Recurrent: Due Date: Frequency: Both Completed Preparation 07-Feb-2014 Due to the Governance and Design risks the Team rates the risk for implementation as substantial. 54

65 Annex 5: Implementation Support Plan THE GAMBIA: Maternal and Child Nutrition and Health Results Project Strategy and Approach for Implementation Support 1. In the run up to this project, the Bank has supported the Government of The Gambia in: (i) drafting the business plan and costing of the strategic plan for nutrition; (ii) the development of a nutrition M&E framework; (iii) supporting the PROFILES assessment (a nutrition advocacy tool); and (iv) strengthening the capacity in financial management and procurement of NaNA. The Bank will continue to provide support to the health and nutrition sectors in implementing this project. The main areas are technical support to the management of RBF approaches; financial management; and M&E. 2. Notwithstanding the ongoing TA, the proposed project will require intensive supervision, technical and implementation support, notably in the first two years, given the fact that: (i) RBF is a new approach to the health and nutrition sectors (it has already been adopted in the education sector); and (ii) the MOHSW has no prior experience with Bank procedures since the Participatory Health, Population, Nutrition Project ( ). A broad range of skills is required for the Bank to conduct effective supervision of the project. Some skills will be needed on a regular basis while others would be required on a need basis. It is therefore proposed to establish a core supervision group that would emphasize financial, procurement, and operational review, complemented by technical assistance in RBF, monitoring and evaluation as well as a community mobilization. The core supervision team includes the following members: (i) a senior nutrition specialist; (ii) a reproductive health specialist; (iii) an operations officer with extensive experience in RBF; (iv) an economist with a strong background in M&E; (iv) a financial management specialist who would review adherence to Bank procedures with regard to fiduciary responsibilities; and (v) a procurement specialist, responsible for procurement, implementation, and institutional issues. If and as needed the team will be expanded to include a communication specialist and a community mobilization specialist. 3. While regular Bank supervision will take place at a minimum frequency of two times per year, this would be leveraged by regular visits by the Dakar-based Bank procurement and financial management specialists to verify progress and provide on-going assistance to the client During the first year or two, an intensive supervision program should be carried out in order to ensure a sound institutional base is put in place in the areas of financial management, procurement, monitoring and evaluation and verification, and interventions are initiated in a timely manner. Moreover, a comprehensive mid-term review will be conducted not later than thirty (30) months after the effective date to ensure the efficient carrying out of the Project and achievement of the Project s objective. 4. The Bank will contract TA on a need basis to provide specialized input in areas such as pricing RBF package of services, quality improvement interventions to improve capacity of the RHT to undertake comprehensive quality of care supervision and in operational RBF data analysis 55

66 Implementation Support Plan 5. The implementation support plan for the project consists of an overall plan for the first 12 months (Table 5.1) and more detailed plans for FM and M&E. Table 5.1 Implementation support plan for first 12 months Focus Skills Needed Resource Estimate Partner Role Technical and procurement review of bidding documents, capacity building FM supervision, technical support, capacity building Project supervision Mid-Term Review Technical assistance Procurement 5 SW N/A FM 4 SW N/A Nutrition Health, RBF M&E Nutrition Health, RBF M&E M&E Communication Organizational management 24 SW Supervision will be coordinated with development partners 4 SW Supervision will be coordinated with development partners IC for 6 weeks IC for 4 weeks IC for 8 weeks In-depth communication expertise will be provided in collaboration with UNICEF 6. The project will be supervised on a risk-based approach. Supervision will focus on the status of financial management system to verify whether the system continues to operate well and provide support where needed. It will comprise inter alia, the review of audit reports and IFRs, advice to task team on all FM issues, review of annual audited financial statements and management letters. Based on the outcome of the FM risk assessment which is Moderate, there will be two on-site visits supervisions per year during the implementation and a review of transactions will be performed on theses occasions. The following implementation support plan is proposed. The objective of the implementation support plan is to ensure that the project maintain a satisfactory financial management system throughout the project s life. 56

67 Table 5.2 FM Implementation Support Plan FM Activity Desk reviews Un-audited financial reports review Audited financial statement reports review On site visits Review of overall operation of the FM system Monitoring of actions taken on issues highlighted in audit reports, auditors management letters, and other reports Transaction reviews (if needed) Capacity building support FM training sessions Frequency Quarterly Annually Semi-annual As needed As needed During implementation and as needed 7. Monitoring and Evaluation: The project will support the capacity of the NaNA and MOHSW for the M&E activities and responsibilities. Support will be provided to develop and strengthen the capacities of the units in charge of M&E through (i) the participation in technical workshops and trainings on monitoring and evaluation activities, and (ii) through the provision of on demand technical assistance missions by technical experts (e.g., consultants). 57

68 Annex 6: Economic and Financial Analysis THE GAMBIA: Maternal and Child Nutrition and Health Results Project I. Background 1. The Gambia is a small country in West Africa with a population of approximately 1.9 million (2013). The population has been growing at a fairly high rate of 3.3 percent per year over the last decade. The Gambia is a low income country with average per capita Gross National Income (GNI) estimated at US$510 (2012) which is less than half of the sub-saharan African average of US$1,255. In the 2011 Human Development Index, the country was ranked 168 out of 187 countries. Life expectancy at birth for the average Gambian is 58 years. 2. The Gambia s performance on MDGs 1c, 4 and 5 has been mixed. While better off than the sub-saharan African average for under-five mortality rate (U5MR) and maternal mortality ratio (MMR), when compared to sub-regional peers like Ghana and Senegal, The Gambia s performance is lagging behind. U5MR and MMR have declined since 1990, but the progress has been modest in relation with the millennium development goals (MDG) 1c, 4 and 5. Preliminary data from the 2013 Demographic Health Survey (DHS), if confirmed, would show encouraging results for U5MR having dropped to 54 per 1,000 live births. No such indication exists for maternal mortality or nutrition. The preliminary data from the 2013 DHS shows no change in underweight prevalence, i.e., 16 percent. According to the 2013 State of the World s Mothers (Save the Children 2013), The Gambia ranks 170 out of 176 countries on the Mother s Index just above Mali, Niger and Central African Republic but behind countries like Chad, Guinea-Bissau and Nigeria. 26 Table 6.1 shows the trends in maternal and child health and nutrition in The Gambia. 3. In response to this scenario, the Maternal and Child Nutrition and Health Results project will prioritize interventions directly linked to the reduction of maternal and child under nutrition, morbidity, and mortality. These interventions will focus on strengthening community structures and the PHC system to enhance the quality and quantity of services by empowering individual women, communities (including community groups) and front line health workers to improve uptake, participation, ownership, caring practices and accountability for maternal and child health and nutrition. 4. The proposed project envisages three complementary components: (i) community mobilization for social and behavior change; (ii) delivery strengthening of selected PHC services and RBF; and (iii) capacity for service delivery. As such, components 1 and 2 will apply RBF mechanisms to address demand- and supply-side challenges as well as social and behavior change for the improvement of maternal and child health and nutrition outcomes, respectively. Component 3 will strengthen overall management capacity (including M&E) of communities, local government and the health system to effectively engage in results-based management. 26 Indicators of the 2013 Mother s Index include: (i) Lifetime risk of maternal death; (ii) Under-5 mortality rate; (iii) Expected years of formal education; (iv) Gross national income per capita; and (iv) Participation of women in national government 58

69 Table 6.1 Health and nutrition indicators, 2005/06 and 2010/ / /13 Trend * Women s health Marriage before the age of 18 years No change Intermittent preventive treatment (IPT) for malaria Improvement Skilled attendance at delivery No change Antenatal care (at least one visit) Deterioration Contraceptive prevalence rate (any method) 13 9 Deterioration Total fertility rate Deterioration Child Health Stunting (height for age) Deterioration Neonatal tetanus protection Deterioration Exclusive breastfeeding under six months Improvement Minimum feeding frequency Deterioration Vitamin A supplementation in children 6-59 months Deterioration Measles immunization by age 12 months No change Oral rehydration treatment Improvement Children under age 5 sleeping under insecticide-treated bed nets No change Antimalarial treatment of children under Deterioration Care seeking for suspected pneumonia No change * No change refers to any difference that is less than 5 percent difference of the 2005/06 value Source: MICS 2005/06, 2010, DHS 2013 Preliminary Report and World Bank Development Indicator database II. Project Costs and Description 5. As indicated in the table below, nearly 29 percent of project costs are allocated for the implementation of Component 1, 29 percent for Component 2, and 27 percent for Component 3. Table 6.2 Project Cost Component Project Cost Percent of Total 1. Community mobilization for social and behavior change % 2. Delivery of selected PHC services % 3. Capacity building for service delivery and RBF % Total % 23. Component 1: Community mobilization for social and behavior change: This component will focus on community-based promotion of key family practices (i.e., the 12 family and community practices that promote child survival, growth and development) 27 and health care 27 Hill Z., Kirkwood B.R., Edmond K. Family and community practices that promote child survival, growth and development: A review of the evidence. WHO, Geneva (2004). 59

70 seeking behaviors for improved maternal, reproductive and child health and nutrition outcomes. There will be: (i) Provision of conditional cash transfers to communities and support groups (VDCs) to increase demand for health and nutrition services through counseling and timely referrals for life-saving health services (e.g., hygiene, sanitation, counseling on infant and young child feeding, delayed first pregnancy and child spacing, referral of pregnant women and children with danger signs to health centers) (ii) Provision of conditional cash transfer (CCT) to individual women to increase utilization of timely antenatal care; (iii) Accompanying measures aimed at promoting behavioral changes and increasing demand to improve household practices related to health and nutrition through social and behavior change communication (SBCC). 6. Component 2: Delivery of selected primary health care services: This component aims to support the delivery of selected nutrition and health care services at primary, and, where needed, referral health care levels, through: (i) performance-based financing (PBF) of health centers for the delivery of a defined package of maternal and child health and nutrition service at primary and referral health care levels; and (ii) start up support (including selected health care waste management measures). A fee-for-services mechanism which includes quantity and quality payments for a defined package of maternal and child health and nutrition services will be introduced. Health centers will sign an RBF contract with the MOHSW and receive quarterly payments corresponding to their achieved performance based on quantity and quality of services delivered. Health centers can use their RBF payments for material and equipment, training, consulting services and operating costs, and staff bonuses. Health providers will invest RBF payments to improve service delivery, motivate staff and develop innovative ways to attract more patients. 7. Component 3: Capacity building for service delivery and results-based management: This component will support: (i) capacity building of MOHSW, NaNA, RHTs, health service providers, VDCs, VSGs and key committees established under the project for effective implementation of the RBF through the provision of technical advisory services and training; (ii) monitoring and evaluation, operational research, and verification of RBF activities including the cost of the IVA, CBOs, and operational research, learning and knowledge management activities,; (iii) project implementation including project management and coordination, fiduciary management (financial management, disbursement, and procurement), oversight, and communications, through the provision of technical advisory services, training and operating costs; and (iv) performance contracts with RHTs, MOHSW RBF Committee and NaNA. III. Development Impact of the Project 8. Malnutrition is a contributing cause to almost half of under-five mortality 28, as well as reduced cognitive development, productivity and life time earnings. Strikingly, various nutritional deficiencies such as stunting, anemia during pregnancy and the first few years of life, 28 Black et. Al. (2013). Maternal and child undernutrition and overweight in low-income and middle-income countries. The Lancet, Volume 382, Issue 9890, Pages

71 low birth weight, inadequate breastfeeding, acute malnutrition (wasting) and iodine deficiency, have each alone been associated with IQ losses varying between 4-18 points. The problem of undernutrition in The Gambia is profound and pervasive. Therefore, malnutrition is a major cause of lost intellectual potential in the Gambian population. This brings serious consequences for the shorter-term physical and cognitive development of affected children, but also in the much longer term, for the economic development of the country. This is mainly through direct losses in productivity linked to poor physical status; and indirect losses due to poor cognitive function and learning deficits, as well as losses resulting from increased medical costs. 9. Intervening in nutrition notably micronutrients and community nutrition is internationally recognized as one of the world s smartest investments, which can generate returns among the highest of 30 potential development investments. 29 Investments in micronutrients were rated above those in trade liberalization, malaria, and water and sanitation. Communitybased programs are also cost-effective in preventing malnutrition, where the benefit-cost ratios for nutrition interventions range from 5 to The need to intervene in nutrition and food security multisectorally that is, by addressing both direct and indirect determinants of malnutrition and during the critical window of opportunity (between conception and the first 2 years of a child s life), is central to this project and will contribute to both the short- and longerterm social, financial, and economic goals of the country. 10. Addressing maternal and reproductive health brings dividends in both the short and long terms. The package of services included in the Project is technically sound and consistent with a series of articles in The Lancet which recommends priority, high-impact interventions to reduce child and maternal mortality rates. Worldwide, pregnancy-related conditions and sexually transmitted infections (STIs) account for one-third of the global burden of disease among women of reproductive age and one-fifth among the total population. Among women of reproductive age in Sub-Saharan Africa, for example, two-thirds of the disease burden for women of reproductive age is attributable to sexual and reproductive health problems. Guttmacher Institute and UNFPA calculate that 250 million years of productive life are lost each year to death or disability resulting from poor sexual and reproductive health (Cohen, 2004). Delaying a first birth and spacing subsequent births result in a higher likelihood of women staying in, having more employment opportunities, and participating politically in their communities. Improved maternal health means fewer orphans and more time for and greater ability of mothers to provide appropriate childcare. One of the most cost-effective interventions is family planning (US$1.55 per new user per year) which can prevent up to one-third of all maternal deaths by delaying childbearing, spacing births, avoiding unintended pregnancies. Family planning can also reduce infant mortality and morbidity through birth spacing and improve adolescent health by reducing high risks of pregnancy-related deaths. For every US$1 invested in family planning, the future savings are as high as US$4 in Zambia, US$7 in Bangladesh and US$8 in Indonesia. Hence, the returns on investment are high especially when integrated with maternal and child health services as in this Project. 29 Copenhagen Consensus Results. Copenhagen Consensus Center, Frederiksberg, Denmark, 2008 and and The Lancet Series on Maternal and Child Undernutrition 2008 and 2013, available from 30 Repositioning Nutrition as Central to Development: A Strategy for Large-Scale Action. World Bank, Washington DC,

72 11. Market failure provides a case for public action on nutrition and health. Although the private returns of improved nutrition and health are high, poor families are inhibited from investing more resources in children because the returns on the investment cannot be seen until years in the future. Market failure in addressing malnutrition and poor health arises from four types of information asymmetry: (a) parents cannot tell when their children are becoming malnourished until severe malnutrition sets in, (b) good nutrition is not intuitive and caregivers do not always know what food or feeding practices are best for their children or for themselves; and (c) people do not know early signs of poor health; and (d) people do not have a high level of knowledge on effective interventions to address health problems. As a result, even when income increases, health and nutrition do not automatically improve. Given the high economic benefits and redistributive effects of investing in health and nutrition, there is a strong case for public intervention for families and parents to get the necessary information for better decision-making and provision of better quality health services. Furthermore, improved health and nutrition can be considered a public good by averting mortality and morbidity, boosting immunity, reducing severity of ailments and therefore increasing labor productivity, yielding benefits for society. 12. The project investments are expected to bring both direct and indirect benefits for the population. Many studies have confirmed the link between adult height and their productivity, estimating that a 1 percent decrease in height is linked to a 1.4 percent decrease in productivity. Inversely, an increase in height is associated with an increase of 2 to 2.4 percent in income. A longitudinal study in Guatemala showed that improved nutrition prior to 3 years of age was associated with improved hourly wage among Guatemalan men. Deficiencies in certain micronutrients on productivity are also significant. For example, studies show that a decrease of hemoglobin level by one percent leads to a reduction of more than one percent in productivity; iron deficiency in children is linked to a reduction of approximately 2.5 percent in future productivity. IV. Economic Analysis 13. An economic analysis was undertaken for the project, using different methodologies for the separate components. The standard cost-benefit analysis was used for Component 1 though with limitations in terms of measuring benefits to all sub-populations. A Marginal Budgeting for Bottlenecks tool was used for a costing analysis of Components 2 and 3 together based on the services included in these components. A. Cost-Benefit Analysis (CBA) and Assumptions for Component Estimating beneficiaries of the project: The direct beneficiaries of the project s Component 1 are children under the age of 5, adolescent girls, and pregnant women in the Upper River, Central River, and North Bank West Regions. To avoid double-counting benefits (e.g. those that accrue intergenerationally, adolescent girls who become pregnant during the course of the project), the CBA was restricted to benefits gained only by children under age 5 years. Benefits to adolescent girls and women of reproductive age (15-49) who will benefit from improved reproductive and maternal health were not included. This implies that the estimated benefits are underestimated, but a more conservative estimate is preferred for the purposes of this 62

73 analysis. Projections from the Gambia Bureau of Statistics (December 2011) are used to determine the number of children under 5 in the North Bank West, Central River, and Upper River regions of the Gambia for the period 31. Assuming that this project achieves 80 percent coverage, the total number of beneficiaries under age 5 in 2014 was estimated at 102,155. For the remaining years of the project ( ), crude birth rates were applied to the estimated population to calculate the number of new births adjusted for infant mortality rate and coverage to calculate the number of additional new beneficiaries each year. The total number of beneficiaries over the project period was estimated to be 183,750 children under age 5. Table 6.3 displays the number of beneficiaries by Region. 15. Estimating benefits from increased lifetime earnings from reduced stunting: A child who is more than two standard deviations below the median (-2 SD) of the WHO reference population in terms of height-for-age is considered short for his or her age, or stunted. This condition reflects the cumulative effect of chronic malnutrition. The focus is on stunting because chronic undernutrition is an indicator of the final nutritional status of the children according to the UNICEF (1998) conceptual framework. This Project will contribute to the amelioration of the underlying causes of undernutrition (food, health and care) by stimulating optimal infant and young child feeding behavior, reducing exposure to diseases, improving food quality (nutrient density), and reducing micronutrient deficiency in vitamin A and iron. All these underlying factors are then expected to jointly influence the final nutritional outcome of the targeted beneficiaries. Evidence indicates that children under the age of 24 months who are stunted would earn significantly lower incomes throughout their productive lives. Given that stunting is irreversible after the age of 24 months, it is critical to intervene early and prevent the onset of chronic malnutrition. 32 While it is possible for some catch-up to occur for children stunted in this early phase in life, most stunted children will remain stunted throughout adulthood. 33 Therefore, if stunting sets in during this critical window, income-earning potential is hindered irreversibly. Evidence from other countries shows that productivity of physical labor declines by 1.4 percent for every 1 percent reduction in height. In 2013, 24.5 percent of children under age 5 were stunted, indicating that nearly a quarter of The Gambia s children will not earn as much as they would have if not affected by stunting. Thus, the benefits of reducing stunting in the project areas are measured by the increased income-earning capacity of the beneficiaries for whom stunting is prevented. The most recent empirical estimates of the negative effects of stunting on worker productivity and adult earnings range from 10 to 20 percent Gambia s lack of progress on malnutrition has substantial implications for economic growth and poverty alleviation. Component 1 is designed in part to address some of the key challenges by increasing the coverage and utilization of community-based child growth and nutrition interventions in selected areas. Standard World Bank methods are used for evaluating projects where investment costs of resources used are compared with the stream of economic benefits. This is the standard cost-benefit analysis, in which the stream of costs are discounted to present values using a discount rate to represent the opportunity cost of capital in the country. 31 The assumption is that the difference between the population of children under 5 and under 6 was negligible. 32 Engle et al Engle et al 2007, Granthan-McGregor et al Hoddinott (2003); World Bank (2006); Quisumbing, Gillespie and Haddad (2003); Alderman Hoddinott and Kinsey (2002); Ross and Horton (2003); Granthan-McGregor et a1 (2007) 63

74 Table 6.3 Project coverage and beneficiaries under age 5 (assuming 80% coverage) Region LGA North Bank West Kerewan Central River Kuntaur Central River Janjanbureh Upper River Basse North Bank West, Central River, and Upper River Regions TOTAL over the project period 183, The benefits of reduced stunting as a result of the project are estimated in this analysis as the present value of the increase in future earnings/income flow of beneficiaries for ages An estimated 15 percent earnings premium is used in the calculations. The assumption is that: (i) the project will be able to reduce stunting rates among the poorest quintiles down to the national average levels (24.5%); and the primary beneficiaries will be the poor and thus rates of stunting among the richer quintiles will not be affected by the project. Because this is likely not entirely accurate, the reduction in stunting is a conservative estimate. Besides, it is assumed that the GNI per capita for the period follows a constant 3.5 percent growth rate - equal to the average annual GNI per capita growth rate for the period. To determine the death rate, birth rate, and neonatal, under 5, infant, female and male adult mortality rates for the period, 7 polynomial regressions are used. Annual adult mortality rates and discount future incomes at a rate of 5 percent per year are accounted for. Therefore, the lifetime discounting factor is the sum of the adjusted annual discounted years from ages 15 through 64 years and interpreted as the number of years earning at the current wage that a child's future lifetime productivity is worth in the present after discounting and adjusting for expected mortality risk. A proportionate cost of Component 1 is used to account for excluding the benefits to women and adolescents US$1.9 million (76% of total cost of Component 1). 18. Assuming 80 percent project coverage, 15 percent earnings premium from reduced stunting, no effect on stunting for better-off households, and 5 percent discount rate, the results of this economic analysis yields a net present value (NPV) of US$1.5 million and Benefit/Cost (B/C) ratio of 2.0 (Table 6.4). A sensitivity analysis was conducted to assess robustness of the estimates. In Scenario 2, earnings premium due to stunting were increased from 15 to 20 percent (as estimated by Granthan-McGregor and colleagues) which yields an NPV of US$2.5 million and a B/C ratio of 2.7. In Scenario 3, earnings premium was reduced to 10 percent which yields an NPV of US$0.5 million and a B/C ratio of 1.3. Thus, the CBA indicates that this is a sound economic investment yielding high benefits even in the conservative scenario. 64

75 Table 6.4 Cost-Benefit Analysis of The Gambia MCNHRP Base Scenario * Million USD Costs Present Value (PV) at 5% discount rate 1.5 Benefits Present Value (PV) of increased lifetime earnings resulting from reduced stunting at 5% discount rate 3.0 Net Present Value (NPV) 1.5 Benefit/Cost (B/C) Ratio 2.0 Sensitivity Analysis Million USD Scenario 2: Stunting earnings premium of 20%; Discount rate of 5% Costs Present Value (PV) at 5% discount rate 1.5 Benefits Present Value (PV) of increased lifetime earnings resulting from reduced stunting at 5% discount rate 4.0 Net Present Value (NPV) 2.5 Benefit/Cost (B/C) Ratio 2.7 Scenario 3: Stunting earnings premium of 10%; Discount rate of 5% Costs Present Value (PV) at 5% discount rate 1.5 Benefits Present Value (PV) of increased lifetime earnings resulting from reduced stunting at 5% discount rate 2.0 Net Present Value (NPV) 0.5 Benefit/Cost (B/C) Ratio 1.3 * Stunting earnings premium of 15%; Discount rate of 5% 19. Additional assumptions make this a likely underestimate of project benefits: i. Only benefits from stunting reduction for the living children were considered and not the influence of stunting reduction on the IMR; ii. Only benefits from stunting were considered and not the influence of other health and nutrition benefits on children under 5; iii. Benefits will be enjoyed by the poorer quintiles for which the current stunting prevalence is above the national average. Improvements will max out at the national average for these quintiles; and better-off quintiles will not reap any benefits from the project. iv. Beneficiaries are restricted to children under 5 and do not include benefits to adolescent girls and women of reproductive age in the analysis. 20. Assumption (iv) above indicates that with 80 percent coverage, nearly 180,173 women of reproductive age will benefit from the project (see calculations below in Table 6.5) but their benefits have not been included in the analysis of Component 1. 65

76 Table 6.5 Project coverage and beneficiaries: women age Region LGA North Bank West Kerewan 21,921 3,035 3,113 3,197 3,279 Central River Kuntaur 19,657 2,722 2,791 2,866 2,940 Central River Janjanbureh 25,171 3,485 3,574 3,670 3,765 Upper River Basse 47,584 6,589 6,757 6,939 7,118 North Bank West, Central River and Upper River Regions 114,333 15,831 16,234 16,672 17,103 TOTAL over the project period 180,173 B. Costing of Components 2 and 3 using the Marginal Budgeting for Bottlenecks (MBB) for the period 21. Reaching the project development objectives implies not only a dramatic expansion of health services and scaling up of high impact interventions, but also the implementation of mechanisms to ensure adequate demand for and use of those services. Components 2 and 3 comprise the health-systems strengthening aspect of the Project. The cost effectiveness and return on investment for Components 2 and 3 were analyzed based on core interventions that will be introduced under these components. The bulk of the resources under these components will go to health facilities under performance-based contracts for the delivery of packages of health services and for the management and TA necessary to enable them to deliver the services. 22. The costing of components 2 and 3 was conducted using the findings of the MBB analysis conducted by the government which informed the Health Sector Investment Case. The MBB is an evidence-based, results-oriented planning and budgeting tool. It utilizes current evidence and knowledge about the possible impact of interventions in reducing morbidity and mortality and aims to set scaling up strategies based on identified current health system bottlenecks. The MBB analysis outlines the cumulative effect of per capita investments in prioritized interventions. The MBB calculates the additional resource requirements to remove health system bottlenecks and implement strategies that enable scale up coverage of high impact interventions. It also estimates the return of increased coverage of interventions in terms of morbidity and mortality reductions. The expected impact on disease specific mortality is a function of efficacy, affected fraction of the population, and the increase in effective coverage for each intervention. Extrapolation from the broader analysis allows conclusions to be drawn regarding the economic benefits of the project on key prioritized interventions noted in the Health Sector Investment Case. The focus of MBB on additional cost and impact in mortality reduction makes it a particularly helpful tool to estimate the extra efforts and resources needed to reach the project development objectives. 23. The MBB analysis has been undertaken using the six coverage determinants 35 of twelve representative interventions from outreach and clinical service delivery modes. The coverage 35 The coverage determinants include: availability of essential commodities, availability of human resources, physical accessibility, initial utilization, continuous utilization, and effective quality. 66

77 determinants include both demand and supply side issues. The process involves systematic identification of bottlenecks and subsequent examination of underlying causes and the development of promising strategies to overcome bottlenecks. 24. Investment scenario: The situational analysis of present progress in expanding health services and improving health outcomes to reach objectives of Components 2 and 3 in the North Bank West, Central River and Upper River Regions, shows that there is a need for accelerated investment. The most significant constraints to rapid scale up are inadequacy, inefficiency of allocation, lack of focus in the PHC and system support. To estimate implementation cost and their impact of components 2 and 3 in terms of mortality and morbidity reductions in the North Bank West, Central River, and Upper River regions, an investment scenario is considered. 25. Assumptions: The scenario is based on ambitious strategies to address existing constraints in drugs and supplies availability, staffing deployment and retention, and health seeking behaviour of the community. It introduced a few interventions as part of the package like rotavirus vaccine, integrated community case management, essential new-born care at community, low birth weight extra care, zinc for diarrhoea management, pregnant women micronutrient supplementation and deworming in pregnancy. This scenario also considers medium expansion of PHC delivery point level including universal access to health centre. Over the three years, a 50 to 60 percent reduction in these various systemic constraints is considered. It makes existing infrastructure fully functional with staffing, equipment and drugs as per the standard to enable health centres to allow Health Centres to provide Basic Emergency Obstetric and Newborn Care and Comprehensive Emergency Obstetric and Newborn Care. 26. Under this scenario, and assuming that national costs are proportional to the total population, the estimate is that The Gambia will require approximately US$23.5 million to implement its scale up strategy to North Bank West, Upper River and Central River Regions (see Table 6.6 below for details). Table 6.6 Estimated costs required (in million US$) Programmatic areas Regional Baseline spending (2012) Total funding needed under Investment Scenario Child Health & EPI RH-MNH Nutrition Malaria Sanitation & Hygiene Communicable Diseases Pharmaceutical Health System Strengthening TOTAL

78 27. Baseline and coverage targets of high impact interventions are provided in Table 6.7. Table 6.7 High impact interventions and indicators by scenario Intervention indicators of population oriented schedulable services Baseline (%) Regional Coverage Targets (%) Investment Scenario % married women using modern method of contraceptives 4 55 % pregnant women who received 4 or more ANC % pregnant women who receive iron supplementation % pregnant women who received 2+ doses of IPT during their pregnancy % children aged 6-59 months who received at least two doses of Vitamin-A in the last 12 months % children aged 2-5 years dewormed 2 times in the last 12 months % mothers and newborns who received 2 follow up visits within 1 week of delivery Intervention indicator of individual oriented clinical services 0 50 Baseline (%) Regional Coverage Targets (%) Investment Scenario % births attended by skilled attendant % children U-5 with SAM received therapeutic feeding The Investment Scenario requires that in order to reduce under-five and maternal mortality by percent and percent, respectively, an additional investment of US$2.71 per capita per year is required on average. It requires only one-thirteenth additional per capita of the current total health expenditure of US$26 per capita. It can be concluded that the benefits from the US$1.95 per capita per year investment from the project (over 5 years to men, women and children) significantly outweigh the costs of retaining the status quo. The project investments from Components 2 and 3 can be expected to bring about reductions in child and maternal mortality by 12.3 percent and 7.5 percent, respectively (Table 6.8). In addition, coupled with the demand-side interventions of Component 1, the health and nutrition improvements gained through the Component 2 and 3 investments will be further amplified. Table 6.8 Estimated child & maternal mortality reduction by the investments in Components 2 and 3 Component 2 & 3 Investment Scenario Reduction in under 5 mortality rate (U5MR) 12.3% Reduction in maternal mortality rate (MMR) 7.5% Per capita investment from Components 2 & 3 US$

79 Annex 7: Map of The Gambia THE GAMBIA: Maternal and Child Nutrition and Health Results Project 69