Tanzania Health Sector Development APL II Region

Transcription

1 PROJECT INFORMATION DOCUMENT (PID) CONCEPT STAGE Report No.: AB5049 Project Name Tanzania Health Sector Development APL II Region Africa Sector Health (80%), Non-compulsory health finance (10%), Central government administration (10%) Project ID P Borrower(s) United Republic of Tanzania Implementing Agency Ministry of Health and Social Welfare Environment Category [ ] A [X] B [ ] C [ ] FI [ ] TBD (to be determined) Date PID Prepared 6 September 2009 Estimated Date of 0 September 2009 Appraisal Authorization Estimated Date of Board 15 December 2009 Approval I. Key development issues and rationale for Bank involvement 1. In 2000, the Government of Tanzania (GOT) embarked upon a long-term (through 2011) program of reform for the health sector which aims to improve access, utilization, quality, and financing of health services through increased efficiency and effectiveness in use and allocation of resources, to maximize impacts on health outcomes, especially among the poor, women, and children. 2. IDA is supporting the implementation of the GOT long-term program through participation in the health Sector Wide Approach (SWAp) and the financing of a slice of the total health expenditures. IDA s support over the period was organized in phases: The first phase of the Health Sector Development Project (HSDP) was a US$22 million Adaptable Program Loan (APL) (HSDP, Credit 800) implemented in It aimed to accelerate the reforms and emphasize institutional capacity development, focusing on: (i) strengthening capacity (particularly at local levels) to manage and adapt to changing roles and responsibilities; (ii) developing and piloting systems to improve quality and delivery of services to improve health status; and (iii) improving resource mobilization and management. The second phase of the Health Sector Development Project is a US$64 million APL (HSDP II, Credit 8410, Grant H0710) approved in 200 and running through December HSDP II supports the implementation of the Second Health Sector Strategic Plan (HSSP) Its objectives are to expand the reforms and systems/capacity development for better management of resources and quality improvements, with a view to institutionalizing decentralized management of health, nutrition and population

2 services at district level and below, and shifting from an input-orientation to output/outcome-based planning and performance management. Originally, the third phase of the Health Sector Development Project was expected to support the final phase of the government s program ( ) with the objectives to institutionalize output-based management, and institute improved systems for high quality care. This third phase was expected to be supported by the Poverty Reduction Support Credit (PRSC) rather than a third APL.. When the second phase of the Project was negotiated in November 200, it was agreed that upon completion of HSDP II (December 2007) the Bank would shift the funds from direct sector support to general budget support (i.e., commit funds through the PRSC rather than through a specific health sector project). However, the conditions for the transition to the PRSC listed in the Development Financing Agreement had not been fully met, and the GOT requested IDA to extend HSDP II for 2 additional years and to seek additional financing in order to (i) continue to support the implementation and objectives of the HSSP through its conclusion; ii) extend the time required to meet the criteria for the transition to the PRSC and to better prepare for it; and (iii) smooth short term delay in anticipated external funds from the US Government for the malaria program. 4. However, since the first Additional Financing, three important developments have occurred, which have an impact on any potential move towards General Budget Support (GBS): (a) The Ministry of Health has adopted a position that only those providing direct support to the health sector (project or pooled funding) should play a role in health sector policy discussions, meaning that a shift to GBS would effectively exclude the Bank from providing health policy input to the sector. (b) An external evaluation of the health sector in October, 2007 (after the first Additional Financing was approved), concluded that the SWAp approach, and the Basket Fund in particular were extremely effective in getting funds to the front line and improving outcomes. (c) As part of the MKUKUTA review (the Tanzanian version of the Poverty Reduction Strategy), an assessment is being done of the effectiveness of different aid modalities, including GBS, basket funds and project-based financing. The results of this assessment are expected later this year and should help inform future financing approaches for the health sector. 5. The proposed Additional Financing will enable IDA to continue to support the implementation and the objectives of the new HSSP III, and will provide transitional financing for pursuing a new longer-term pooled funding arrangement. Bridge financing is needed to allow time to include such an operation in the CAS and pursue project preparation. In light of these developments, the GOT has requested IDA to: (i) extend HSDP II for one additional year; and (ii) to provide Additional Financing in order to sustain support for the HSSP. This additional financing would be used both to address an ongoing funding gap, and finance additional interventions which would enhance the project s development impact and effectiveness. Despite the significant amount of external financing coming into the health sector,

3 the Health Basket Fund (HBF) remains the only vehicle for providing significant amounts of external support (either in cash or in kind through drugs and medical supplies) directly to frontline health services at the district level. Support for this area is essential for strengthening the overall health system and ensuring that external financing for vertical programs is well utilized. 6. IDA resources and the Bank s expertise will complement those provided by other partners. The Bank is the one partner who can forge necessary linkages between the public sector reforms and the health sector reforms, and the Bank Team will complement technical/policy guidance provided by other partners with its global experience in health systems, financing and human resources for health. External financing targeted to the sector has been essential for addressing delays in GOT financing and meeting valid, but unanticipated, sector budget requirements. In the longer term, IDA resources should be disbursed through the budget or a multi-sector pooled fund mechanism, a larger share of public expenditure should be allocated to the health sector and sectoral budgeting and financial management should improve, but for medium-term term, IDA financing at the sectoral level will be critical to enabling the health sector to contribute towards achieving the MDGs. II. Proposed objective(s) 7. The development objective and expected outcomes of the Additional Financing are identical to the original project, although outcome indicators have been revised upwards to reflect the one year extension of the project. The Project Development Objective (PDO) is therefore: to achieve improvements in the provision of quality health services through continuing to support the reforms, capacity development and improved management of resources while focusing on quality III. Preliminary Description 8. About three quarters of the Additional Financing (US$0 million) will disburse under Category 1 (Pooled Funds Expenditures financed under the Subprograms of the Health Sector Strategic Plan (HSSP)) of the existing Development Financing Agreement (DFA). Specifically, through the pooled fund, IDA Additional financing will support activities for FY 09/10 and FY 10/11 at central, regional, district level and at secondary/tertiary hospitals level with a focus on health service delivery and quality. An essential element of this support will be increasing the funds flowing to districts from $1.00 to $1.25 per capita, as well as support for essential commodities. 9. The remaining twenty-five per cent (US$10 million) will disburse under Category 2 (Non-Pooled Expenditures financed under the Subprograms of HSSP) of the existing DFA. This area will support key high priority investments, including essential medical equipment for Emergency Obstetric Care and other high priority areas such as diagnostic services, support to health human resources development, and the introduction of a comprehensive food fortification program for Tanzania to reduce the high prevalence of micro-nutrient deficiencies in the population. These areas are specific, high-value activities which are difficult to fund through the HBF, have been identified by the Ministry of Health and Social Welfare (MOHSW) as the major gaps in existing Government and/or external financing. The HSDP II Project was designed to facilitate disbursements both through the pooled fund and outside of the pooled fund. The exact

4 distribution of funds between the pooled and non-pooled categories will be fixed during project preparation and appraisal, but efforts will be made to maximize the use of pooled funding arrangements. IV. Safeguard Policies that might apply 10. No new construction or acquisition of land is supported under the program. To mitigate potential harm caused by improper disposal of medical waste, the Health Care Waste Guidelines and the Management Plan adopted under HSDP II will continue to be followed. The Plan focuses on (i) legislation and regulation; (ii) standardizing practices; (ii) collection, storage and disposal; and (iv) capacity and management. Implementation of the Waste Management Plan does not involve any new construction or acquisition of land. Guidelines on incinerators and waste pits imply adaptations to or replacement of existing facilities that occupy existing sites on facility grounds. Safeguard Policies Triggered by the Project Yes No TBD Environmental Assessment (OP/BP 4.01) [X] [ ] Natural Habitats (OP/BP 4.04) [ ] [X] Pest Management (OP 4.09) [ ] [X] Physical Cultural Resources (OP/BP 4.11) [ ] [X] Involuntary Resettlement (OP/BP 4.12) [ ] [X] Indigenous Peoples ( OP/BP 4.10) [ ] [X] Forests (OP/BP 4.6) [ ] [X] Safety of Dams (OP/BP 4.7) [ ] [X] Projects in Disputed Areas (OP/BP 7.60) * [ ] [X] Projects on International Waterways (OP/BP 7.50) [ ] [X] Piloting the Use of Borrower Systems to Address Environmental and Social Issues in Bank-Supported Projects (OP/BP 4.00) [ ] [X] V. Tentative financing Source ($m.): Borrower/Recipient 1,5.0 Other development partners IDA 40.0 Total VI. Contact point Contact: Dominic S. Haazen Title: Lead Health Policy Specialist Tel: Fax: dhaazen@worldbank.org Location: Dar es Salaam, Tanzania * By supporting the proposed project, the Bank does not intend to prejudice the final determination of the parties claims on the disputed areas

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