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1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Human Development I1 Country Department 11 Africa Region Document of The World Bank FOR OFFICIAL USE ONLY PROJECT APPRAISAL DOCUMENT ON A PROPOSED CREDIT IN THE AMOUNT OF SDR 16.6 MILLION (US$25 MILLION EQUIVALENT) TO THE REPUBLIC OF GUINEA FOR A HEALTH SECTOR SUPPORT PROJECT MAY 4,2005 Report No: GUI This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not be otherwise disclosed without World Bank authorization. A

2 CURRENCY EQUIVALENTS (Exchange Rate Effective March 3 1, 2005) Currency Unit = Guinean Francs GNF2,847 = US$1 US$l = SDR 1 FISCAL YEAR January 1 - December 31 ABBREVIATIONS AND ACRONYMS APL CAAPR CRD DAAF DPS DRS EPI FMA GDP IMCI MAP MDG MOF MOH MURIGA OED PACV PRSP PRCI SOE STIs SWAP EOC TBA Adaptable Program Lending Country Financial Accountability Assessments and Procurement Review Rural Development Community Financial Directorate Prefectoral-level Health Department (Direction prkfectorale de la santk) Regional-level Health Department (Direction rkgionale de la sa&) Extended Program of Immunization Fiduciary Management Agency Gross National Product Integrated Mother/Child Interventions Multi-sectoral AIDS Program Millennium Development Goals Ministry of Finance Ministry of Public Health Reproductive Health Mutuals (Mutuelles de Risques de Grossesses et d 'Accouchements) Operations Evaluation Department Community Support Program (Bank-financed project) Poverty Reduction Strategy Paper Capacity Building for Service Delivery Project (Bank-financed project) Statement of Expenditures Sexually-transmitted infections Sector-wide approach Emergency Obstetrical Care Traditional Birth Attendant Vice President: Country Managermirector: Sector Manager: Task Team Leader: Gobind T. Nankani Mamadou Dia Alexandre V. Abrantes Ibrahim Magazi

3 FOR OFFICIAL USE ONLY GUINEA HEALTH SECTOR SUPPORT PROJECT CONTENTS Page A. STRATEGIC CONTEXT AND RATIONALE B Country' and sector issues... 1 Rationale for Bank involvement... 3 Higher level objectives to which the project contributes... 3 PROJECT DESCRIPTIQN... 4 Lending instrument... 4 Project Development Objective and Key Indicators... 4 Project Components... 5 Lessons leamed and reflected in the project design... 8 Altematives considered and reasons for rejection... 8 C. IMPLEMENTATION Partnership arrangements... Institutional and implementation arrangements Monitoring and evaluation of outcomes/results *.. 4. Sustainability Critical risks and possible controversial aspects Loadcredit conditions and covenants D. APPRAISAL SUMMARY Economic and financial analyses Technical Fiduciary Social Environment Safeguard policies Policy Exceptions and Readiness Annex 1: Country and Sector or Program Background This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not be otherwise disclosed without World Bank authorization.

4 Annex 2: Major Related Projects Financed by the Bank and/or other Agencies Annex 3: Results Framework and Monitoring Annex 4: Detailed Project Description Annex 5: Project Costs Annex 7: Financial Management and Disbursement Arrangements Annex 8: Procurement Annex 9: Economic and Financial Analysis Annex 10: Safeguard Policy Issues Annex 11: Project Preparation and Supervision Annex 12: Documents in the Project File Annex 13: Statement of Loans and Credits Annex 14: Country at a Glance MAP: IBRD No

5 GUINEA HEALTH SECTOR SUPPORT PROJECT PROJECT APPRAISAL DOCUMENT AFRICA REGION AFTH2 Date: May 4, 2005 Country Director: Mamadou Dia Sector ManagedDirector: Alexandre V. Abrantes Project ID: PO65126 Lending Instrument: Specific Investment Loan Team Leader: Ibrahim Magazi Sectors: Health (100%) Themes: Health system performance (P) Environmental screening category: Partial Assessment Safeguard screening category: Limited impact [ ] Loan [XI Credit [ ] Grant [ ] Guarantee [ ] Other: For Loandcredit s/o thers : Total Bank financing (US$m.): ASSOCIATION Total: Borrower: Republic of Guinea Responsible Agency: Ministry of Public Health BP 585 Commune de Kaloum, Boulevard du Commerce Conakry, Guinea Tel: (224) pdramou@biasy.net Expected effectiveness date: October 3,2005 Expected closing date: September 30,201 1 Does the project depart from the CAS in content or other significant respects? Does the project require any exceptions from Bank policies? Have these been approved by Bank management? Is approval for any policy exception sought from the Board? Does the project include any critical risks rated substantial or high? Does the project meet the Regional criteria for readiness for implementation? [ ]Yes [XINO [XIYes [ ]No [XIYes [ ]No

6 ~ Which Project development objective Help decrease maternal and infant mortality rates by: (a) avoiding the death of at least 12,000 pregnant women, and (b) avoiding the dealth of 27,500 children. Project description [one-sentence summa y of each component] The project will have two components: (a) Strengthening Health Care Services (b) Institutional Strengthening safeguard policies are triggered, if any? Environmental Assessment (OP/BP/GP 4.0 1). The project is Category B. Significant, non-standard conditions, if any, for: Board presentation: Loadcredit effectiveness: Covenants applicable to project implementation: Contract with GTZ for health services quality enhancement finalized and accepted by both parties before

7 A. STRATEGIC CONTEXT AND RATIONALE 1. Country and sector issues Guinea is one of the poorest countries in Africa with a per capita GDP of US$560. According to latest estimates, 40 percent of the population lives below the poverty line with less than US$300 per year. Life expectancy at birth is 47 years, and 38 percent of the population is not expected to reach the age of forty. Only 52 percent have access to safe water and 55 percent to health services. Health services in Guinea virtually collapsed during the many years of economic stagnation in the s. Recovery started in 1986 when a new health policy was formulated which focused on improving primary health care coverage and quality of services. Adoption of the Bamako Initiative, with support from multiple donors, helped communities take greater responsibility in the management of health resources and ensured rapid expansion of services in rural areas. The results have been telling: immunization coverage and continuity, antenatal care, treatment of diarrhea, etc. have all improved during 1990s. The annual per capita visits to public facilities increased remarkably. Health outcomes like child mortality have shown dramatic reductions. Between 1992 and 1999, the urban under-five mortality rate decreased from 167 to 133. The decrease was more pronounced in rural areas where under-five mortality rate dropped from 247 to 187, a 24 percent decline as compared to 20 percent for urban areas. This has been attributed to the success of community-based health services introduced in rural Guinea from the 1980s. Despite the significant progress, health outcome indicators remain mediocre compared to other parts of the world, and the country s perfonnance in this regard is lower than expected for its level of per capita GDP. This is due to two main reasons. Low cost interventions such as prevention and treatment of malaria, or early treatment of diarrhea and upper respiratory infections could bring about significant improvements only to a certain extent but require back-up from higher referral levels to decrease it further. Inequities in access and utilization of services still persist in spite of the best intentions of the community-based approach. Thus, children born to the poorest 20 percent of population were twice more likely to die before reaching their first birthday than those in the richest 20 percent of the population in both 1992 and Fertility has also remained high and contributes to maintaining the particularly high level of maternal mortality as one out of seven woman dies due to pregnancy. Fertility rate i s extremely high in rural areas where it even appears to have slightly increased from 5.9 to 6.1 between 1992 and This increase is presumably a result of shorter breast-feeding periods now being practiced in rural areas of the country and no increase in the use of modern contraceptive methods. For sustaining the momentum gained in the improvement of health in Guinea, more resources would be necessary. However, simply increasing allocations would not do much good if technical and balanced efficiencies are not ensured. The momentum generated in health sector improvements during the 1990s need to be sustained, and strategies for poverty reduction through health sector need to build on existing strengths (such as community based health care via the Bamako Initiative) while gaps and weaknesses are addressed. Some of the main issues identified in the 2002 Country Status Report on Health are as follows: a) Relatively poor health outcomes: Although indicators are improving they are still below what they should be compared to other African countries. Contraceptive prevalence in Guinea is about 5%, maternal mortality is high, and neonatal mortality accounts for 50% of the deaths during the first year of life. b) Inequity: Over the last decade, public expenditures focused primarily on services in urban areas with emphasis on Conakry, and overall benefited the wealthier income groups. More than 60% of health personnel is in Conakry serving only 20% of the country s total population. Health indicators vary widely 1

8 by Region. Public expenditures seem to benefit the rich more than the poor as hospitalization is the most subsidized of public health services and the 10% wealthiest use almost a quarter of the hospitalization expenditures. c) Insufficient Health expenditures: Health expenditures in relation to total government expenditure are extremely low in Guinea. Government spending on health even decreased from less than 1% of GDP in 1993 to approximately 0.75% in The sector s recurrent expenditure represents only 5.6% of the country s total recurrent budget, and the share of health sector investment budget is around 4.75 of the Government s total investment budget. Health sector budget allocations have been invariably low over the past decade, representing less than /4 of the education sector budget allocation, when in most countries this ratio is closer to half. d) Poor Budget execution: The already low budgetary allocation is further hampered by poor execution; the executed budget is 30% of the allocated budget, according to a Health Expenditures Tracking Survey undertaken in This is due to: (a) treasury constraints at the MOF level; (b) non-compliance with effectiveness or a priori disbursement conditions agreed to with donors; (c) administrative delays; and (d) contract or/supplier reliability. e) Human resources problems: There is a major problem of shortage and distribution of skilled health personnel in the country. This is worse in rural areas and explains the inequities and poor quality of maternal and child health services. For example, while 71% of pregnant women visit an antenatal clinic at least once, only 35% receive skilled attendance during delivery. Studies indicate problems of low level of salary and incentives of nurses in rural areas. The share of expenditures on salaries has remained unchanged in the last decade, and even deteriorated at the primary care level. This contributes probably to the low perceived quality of services, and, in addition to lack of personnel in rural areas, might explain the low rate of return visits. f) Lack of inclusion of the private sector into the health system: Only about 10% of all health expenditures in Guinea are public, the rest comes mainly from out-of-pocket. Most of this out-of-pocket money is used to buy services fkom the private sector. Yet, no effort has been made to date to try to harness the potential of the private sector to reach public health goals. In addition, the problem of govemance has reached unprecedented levels lately. A study undertaken in 2000 on parallel payment practices in the two main hospitals of Conakry showed that one patient out of three who benefits fkom services is not registered anywhere, that patients pay about 10 times the official fees for being treated as in-patients, and that only 14% of what patients pay go into the hospital s coffers. Those practices are in part linked to the human resources problems mentioned above. Even the Bamako Initiative, which has long been an example for the rest of Africa, seems to not be adhered to by some people. One of the reason is that the commercial bank where the health committees kept their money went bankrupt and the money became unavailable for a while. Another problem is that the Ministry of Finance asked a couple of times that some of the money from health committees be sent to Conakry, to the Treasury, thus touching upon one the principles of the Bamako Initiative which is that cost-recovery money belongs to health committees. Those factors are the essential ones which explain an under-utilization of the health structures at the different levels of the system. Government is well aware of those factors and has taken several steps to address them, among which: (i) it started to redeploy some health personnel from the central hospitals to rural areas in early 2004; (ii) it has designed a comprehensive Five-Year Plan ; (iii) the Five Year Plan includes ways to work with the private sector. 2

9 2. Rationale for Bank involvement This project would complement other instruments which are in existence in Guinea (the PRCI, PU 111, and PACV projects). It builds on the successes of Guinea, particularly its primary care mobilization experience. It should be seen as a transition project towards a full budgetary support through a PRSC when the sector is ready for it (see Annex 3, suggested criteria to determine when the sector will be ready for full budgetary support). It is clear that Guinea is still unused to the program approach, but the Ministry of Health is making an effort to coordinate donor participation in one homogenous 5 year plan. The Bank s experience and support of this approach makes its participation important and useful. For the proposed project, however, the Bank would proceed as with a classic investment project, selecting priority areas in which to intervene, rather than playing the role of lender of last resort. The Bank also helped Government in its programmatic approach by conducting a joint technical appraisal with the European Union, GTZ, UNICEF and France. It was decided to focus this project on improving the maternal mortality rates because maternal mortality is a good proxy for how the health system in its entirety i s performing. Compared to some other indicators such as immunization rates, which can be increased substantially through a quick campaign but which do not improve the health system delivery, maternal mortality requires, for it to be improved, that community mobilization be undertaken so that at risk pregnancies be detected, that there be primary care available and utilized, that the referral system for emergency care works and be of good quality. 3. Higher level objectives to which the project contributes The overall objective of the MOH Five-Year Plan , which this operation would support, is to improve the health status of the population while reducing inequities. The MOH Five-Year Plan contributes to reaching the objectives of the PRSP related to maternal mortality and to under-five mortality rates, which are consistent with the MDGs. The CAS main objective is to support the implementation of Guinea s PRSP. The project by supporting the PRSP implementation through its support of the MOH Five-Year Plan, would help Guinea in achieving health specific MDGs as reflected in the PRSP objectives. The proposed project is included in the CAS (page 22, paragraph 78 of the CAS report) as the second part of an Adaptable Program Loan (APL) which was estimated at the time at US$15 million. Following appraisal, it was determined that in order for the project to have an impact in the sector, a larger IDA allocation was needed. One of the main priorities of the PRSP being improvement in the health sector, a slight redistribution of the IDA allocations was done to allow the credit amount for this project to be increased to US25 million. 3

10 PRSP Objectives for Guinea (country-wide) Obi ectives I Indicators I Data 1 Data 1 Est. 1 Est. 1 Est. I a) Decrease by 2/3 under five mortality rate between 1990 and b) Decrease by % maternal mortality between 1990 and 2015 c) Keep the AIDS epidemic below 5% by 2015 circa circa circa circa circa " a.1) Under five mortality rate 229 ('92) a.2) Infant mortality 136('92) 98 ('99) a.3) % of children less than one 35 ('90) 52 ('01) year of age vaccinated against measles a.4) idem for DPT3 17('90) 43 ('01) b.1) Maternal mortality rate 666('92) ('99) b.2) % of assisted birth 30,5 ('92) 34, ('99) c.1) HIV prevalence among 298 <5 <5 <5 pregnant women years old c.2) Rate of condom use 4,8 ('92) ('01) 6' ('99) B. PROJECT DESCRIPTION 1. Lending instrument Although a budgetary support approach is being considered for Guinea in the years to come, the conditions are not yet met. Consequently the proposed project would follow a relatively classic investment approach, with the difference of working on a health sector program, in close collaboration with other donors and maintaining project management within the Ministry of Health (see details in Annex 2). Considering the governance and equity problems which Guinea faces, Government decision to use a program approach is the most sensible in order to use its human resources in the most efficient way possible and avoid a scattered approach. 2. Project Development Objective and Key Indicators Although the MOH Five-Year Plan will contribute to reaching the objectives set in the PRSP, it was agreed that the most pertinent indicator to reflect an overall improvement in health services and consequently the health of the population would be that of a decrease in the rate of maternal mortality. This decision was based on the rationale that (i) maternal mortality is particularly elevated in Guinea; (ii) to reduce maternal mortality the entire health system need to be reinforced (which is not the case for other indicators which could result from factors other than proper health services alone), and (iii) to improve this indicator the MOH will have to focus on the poorer populations. The objective of the Project is to contribute to reaching the maternal and under-five mortality reduction objectives of the Five-Year Plan Program, of the Poverty Reduction Strategy Paper of the Borrower, and the Millennium Development Goals. This project would thus contribute particularly to reaching the following impact: (a) help decrease maternal mortality rate from 528 per 100,000 live 4

11 births in 1990 to slightly above 200 per 100,000 live births at the end of the project in the 18 targeted prefectures; and (b) help decrease infant mortality from 98 deaths of children under one year of age per 1,000 live births in 1999 to around 50 deaths4,000 at the end of the project in the 18 targeted prefectures. This would be achieved by avoiding the death of at least 12,000 pregnant women, and avoiding the death of 27,500 children less than one year of age. To have this impact, the project would: help improve demand, access, and quality of health care services in at least 250 health posts, 200 health centers, 18 hospitals and 2 improved health centers throughout the 18 poorest prefectures; improve coverage by increasing assisted births from 42% to 65%, and vaccination rate for DTCP3 from 70% to 90%; increase cesarean sections from 1.8% of births to 5%; and help increase demand, by creating 130 new health mutuals or MURIGAs, and ensuring that at least 2 health centers/prefecture are to be managed by the communes or CRDs if the pilot project on this aspect is conclusive. A complete list of indicators is available in Annex 3. The target prefectures have been selected based on the national poverty map with Gueckedou and Kissidougou added due to the stress those two prefectures have sustained lately because of the influx of refugees from neighboring countries (see list in Annex 4). This is intended to reach the objectives since those prefectures are usually the ones with the worst indicators. Guinea already benefits from a Multi-Sectoral AIDS Project (MAP) which became effective in March The country also received financing from the Global Fund to address the HIViAIDS epidemic in Therefore, the present operation would not invest in this area. HIV/AIDS indicators are monitored by the MAP. And, although those indicators would be looked at during each annual review of the Five-Year Plan, the present operation would not be held accountable for those indicators. 3. Project Components It was agreed that the Bank s comparative advantages would be channeled into activities around the following two components: 9 Component I: Strengthening Health Care Services (US$18.99 million) This component would help strengthen health posts, health centers and hospitals in the 18 selected prefectures to give quality services to at least one million pregnant women and 933,000 children less than one year of age. The package of health services that would be reinforced are those for prenatal care, normal and emergency delivery for women, and those of the integrated management of childhood diseases, as well as control of communicable diseases (TB, malaria). o Sub-component A - Quality of care. Investments would be made in particular to: (i) reinforce the chain of care for at-risk deliveries, starting with early identification by village traditional birth attendants (TBAs); (ii) improve the norms and adherence to the norms for basic as well as emergency birth delivery in public and private health centers; (iii) improve emergency birth delivery care at the higher levels of the network, namely in Centres de SantC AmCliorCs, private clinics (including NGOs) and prefectoral hospitals; 5

12 (iv) increase utilization of family planning services and of IMCI activities, namely EPI, diarrhea control, acute respiratory illnesses, malaria, nutrition; (v) ensure a steady supply of drugs, vaccines and other medical supplies; (vi) strengthening of the roll-back malaria program, through malaria prevention, treatment, and operational research via insecticide-treated bed-nets, anti-malarial drugs, and advisory services; (vii) improve access to care by improving the referral system via radio and ambulances; (viii) implementation of the existing on-the-job master plan would be financed, along with assistance to the training of more midwives. Since the new mid-wives would not be available for three years, contracting of retired or other midwives would be implemented to fill the gap especially in rural areas. This sub-component would be implemented mainly through performance-based contracts signed between the MOH and health centers and district hospitals (agreements), and private clinics (including NGOs) (contracts), o o Sub-component B - Community mobilization. Investments would be made mainly to:. Support the existing successful MURIGA system, which is a health mutual system implemented during the previous Bank-financed project, and which. provides coverage mainly for women s health risks related to child birth. Health mutuals, which cover more risks than the MURIGAs, would also be developed. In order to strengthen the Government s policy for decentralization, some health centers would be managed by communes and CRDs, starting with a pilot activity in six prefectures the first year. The evaluation of this pilot would help decide how to extend it to the other 12 prefectures covered under the project.. Re-energizing of health committees around health centers would be done by ensuring that health centers who serve poor populations receive their government allocation - as they only receive 30% now according to the Health Expenditures Tracking Survey carried out in In order to improve governance, the publication of the budget received by each health structure and how the money was spent will be done throughout the country so that the population is aware and. government officials are accountable to them. Community sub-projects would be financed mainly village-level awareness activities related to (i) the development of MURIGAs, (ii) the early detection of at-risk pregnancies and their follow-up, and (iii) the full DPCT3 immunization which needs three repeated visits. Sub-component C - Ouality Insurance. The MOH has taken the option to improve utilization of health services by strengthening their quality. Such a system has been put in place with the help of GTZ in two prefectures. Evaluation of this pilot took place at the end of Preliminary evidence seems to indicate that this approach is successful. The project would help extend this improved system to all 18 targeted prefectures. Following a self-evaluation, health structures decide on a plan to improve several basic aspects of health care: technical skills, client satisfaction, medical waste management, continued training, community participation, management of the district, financial management, and health center performance. The best plans would be rewarded through quality incentive grants. Then each structure plans its annual operation plan based on its diagnosis. The project would help finance both the self-evaluation process as well as parts of the annual operation plan. GTZ would be hired on a sole-source basis to help the MOH manage this component. This decision was taken since GTZ is already doing so for other prefectures and since the German government plans to co-finance in a parallel way parts of the technical assistance required for the extension to the 18 targeted districts. 6

13 k Component I1 - Institutional Strengthening (US$8.37 million) Investment would be made to increase coordination and monitoring and evaluation. A Pilot Committee for the Five-Year Plan would be put in place along with a Task Force for the project. The Task Force would focus on facilitating technical implementation of the project and ensuring its objectives are reached, and the credit would finance the necessary supervision costs, studies, operations research, workshops, study tours in the region. The credit would help finance integration of maternal mortality into the health information system, which involves mainly some technical assistance and workshops. The project would help strengthen the leadership and policy making capacity of the MOH as well as support the development of health sector reforms. The project would strengthen the MOH s Administrative Unit (DAAF) and decentralized units in order to prepare them for budgetary support. This would be done first by hiring a Fiduciary Management Agency (FMA) which would transfer certain competencies each year to the DAAF as part of its contract in financial management and procurement. Also financial audits would be carried out on those decentralized structures and they would all receive assistance to meet certain basic requirements in terms of financial management and contract management. Office and computer equipment and furniture would be provided to this unit. The project would strengthen the structure in charge of developing the national insurance scheme therefore it would finance the recurrent costs of this unit, its logistical support (transport and computer system), technical assistance;workshps, and study tours in other African countries. A yearly health expenditures tracking survey would be undertaken to see if there s any improvement. Finally, the purchasing function of the MOH would be improved in terms of public-public contracting between the MOH and municipalities or Rural Development Committees (CRD) (agreements), and between the MOH and private service providers (contracts). To complement other financing (UNFPA in particular) which are helping build a new Reproductive Health Training and Research Center in Conakry, the credit would help finance equipment of that center if the center i s made available before the Mid-Term Review. Support would be provided the further implement the country s Medical Waste Management Plan (MWMP), more particularly in hospitals at the prefecture level, health centers at the village level, and health posts in rural areas, with the provision of incinerators where necessary, safety equipment, training of these health facilities personnel, and awareness campaigns for the general public. Project management and coordination would be financed through provision of equipment, vehicles, technical advisory services, including for the purpose of research and studies, and training, including workshops and study tours, to entities involved in Project implementation, as well as incremental operating costs of these entities. 7

14 4. Lessons learned and reflected in the project design This operation builds on the lessons learned from three previous health operations financed by the World Bank since 1988 (see Annex 15, where the Guinean coordinators of those projects themselves listed the lessons to retain). For example, working at the community level, reinforcing the Bamako Initiative and introducing health mutuals is something that was seen as very positive and would be financed again here. This operation would also build on existing successful operations, namely the Urban Project I11 which has started writing agreements between the central govemment and municipalities. The MOH would follow the same approach and strengthen this system by better defining the role of the DRS and DPS in relation to elected bodies such as municipalities and CRDs. Finally, preparation of this project benefited from sector work such as the Health Expenditures Review, the Health Expenditures Tracking Survey, the Guinea Country Status Report, which all provided insight on problems to be tackled. 5. Alternatives considered and reasons for rejection At the outset of project preparation, because of the interest in moving towards budget support, a SWAP approach was considered. However common pooling of donors resources was not considered feasible in the context of the problems which the Public Expenditures Review highlighted. It was also originally considered that the World Bank be the lender of last resort, however this idea was dropped in order to ensure that specific outcomes be linked to the project s inputs in the poorest areas of the country. C. IMPLEMENTATION 1. Partnership arrangements The Five-Year Plan will be financed on a yearly basis, and the MOH will prepare a yearly review with details on who finances what. A yearly review will take place, led by the MOH, and donors will be provided with a review of the previous year progress of the Five-Year Plan, evaluation of progress relative to objectives, as well as planning for the next year. However, financing will be parallel, not pooled. During project preparation, the Bank team held joint missions with the European Union, France, GTZ, and UNICEF. It is expected that the yearly reviews would be held jointly along with other donors. 2. Institutional and implementation arrangements There would be no separate implementation unit, but the project would be placed under the leadership of the MOH s Secretary General. Support would be provided to the DAAF of the M OH to manage the IDA credit. A Fiduciary Management Agency would be hired to help the DAAF in certain functions. This FMA would be evaluated yearly partly according to how successful it has been in ensuring that the MOH s DAAF can now implement certain functions, in order to ensure a phasing out of the FMA 8

15 The project s Task Force, also under the supervision of the Secretary General, would follow its technical implementation and would ensure objectives are reached. The project would finance the recurrent costs of this Task Force, its logistical support (transport and computer system), technical assistance, and study tours in other African countries. Institutional responsibilities for the Medical Waste Management Plan would rest (a) for the overall responsibility, with the MOH Directorate of Equipment and Infrastructure (DIEM), and (b) for the decentralized levels, with the General Director of Hospitals, the Head of the Health Centers and of the Health Posts. 3. Monitoring and evaluation of outcomes/results A yearly health expenditures tracking survey would be carried out, as well as a yearly client satisfaction survey focusing on quality of care. Those two tools along with data from the health information system, would provide the data necessary to assess progress and identify bottlenecks. Guinea has a management information system quite sophisticated where a monitoring of health centers activities and finances is undertaken every six months, thus providing facility-based information. For evaluation purposes, a DHS was be carried out in 2004 which will serve as base-line. The project would co-finance another such survey for evaluation purposes in 2009, towards the end of the project. Prior to the Mid-Term Review, studies and surveys would be carried out to measure progress toward attaining the development objectives of the project. 4. Sustainability This operation is a regular investment loan which continues the Bank s support to the health sector as it was preceded by a first phase of a three-phases APL. The Bank decided to discontinue the APL mode as it intends to eventually move towards a PRSC approach. This operation would contribute to prepare the MOH for such PRSC approach by consolidating its capacity to carry out a program and align donors behind such program 5. Critical risks and possible controversial aspects Critical risks. There are two main risks: P One is that some donors might not conform to the programmatic approach, however, there s evidence of good intentions from most donors in Guinea to that approach. There is strong agreement between the borrower and the Bank on the sectoral strategy and issues and a high degree of buy-in from major stakeholders: the MOH has prepared its health strategy in a participative manner and is ready to implement it. 9 Second, the country s macroeconomic, political environment and governance issues, are a problem. At the time of the writing of this report some government reshuffling is expected. The macro-economic situation is at its lowest point. Governance is a major issue. However, it s expected that this operation would help the latter point by (i) monitoring the flow of money to the lower levels; (ii) increasing public knowledge of how much money each health infrastructure receives and what it uses this money for; (iii) hiring a FMA which would little by little improve the DAAF management. 9

16 There is no environmental or other safeguard issues that may affect the project, but it will contribute to improving medical waste management in the 18 prefectures covered by the project.. Risks To project development objective: - lack of leadership from the MOH To component results: -lack of counterpart funds -human resources are not be deployed to rural areas -weak capacity - by MOH to.. monitor performance-based Risk Mitigation Measures Build a strong Task Force for the project with main Directors c onc emed -Health is one of the priority areas of Government. -New country financing parameters would be applied -Hire retired or private midwives as contractors -Hire third party.~ to monitor agreements Risk Rating with mitigation S M IM M 6. Loadcredit conditions.and covenants Conditions of Effectiveness: e e e adopted the Project Implementation Manual and the Financial, Administrative and Accounting Procedures Manual in form and substance satisfactory to the Bank; made the initial deposit of GNF 350,000,000 counterpart funds equivalent in the Project Account; entered into a contract with the Fiduciary Management Agency under terms and conditions satisfactory to the Bank, Project financial, procurement, and contract management, and knowledge transfer in those areas; concluded performance-based contracts, in form and substance satisfactory to the Bank, with at least 10 health structures in the 18 targeted Prefectures; and recruited the independent financial auditors, under terms and conditions satisfactory to the Bank. Dated Covenant: GTZ contract finalized and accepted by both parties before October 1,2005. D. APPRAISAL SUMMARY 1. Economic and financial analyses A mid-term expenditures framework exercise was conducted during project preparation which helped the MOH scale down its Five-Year Plan to more realistic expectations. The MTEF also helped identify the needs for continued donor support. 10

17 2. Technical The program approach seems most justified in those difficult times for Guinea where financial and human resources are stretched to their maximum due to macro-economic problems, and where the traditional project approach would scatter resources. The program approach would also help MOH prepare for budget support by using only one Action Plan and preparing yearly reviews. Targeting the poorest provinces ensures that indicators will improve. 3. Fiduciary Financial Management Aspects: The Ministry of Health (MOH) which would be the implementing agency for the project does not have capacity and adequate financial management system in place. The MOH would therefore contract a Fiduciary Management Agency (FMA) as a financial management firm which would have the responsibility for the project s financial management under the responsibility of the Head of the Directorate of Administrative and Financial Affairs (DAAF) of the MOH. The FMA is yet to be recruited. Therefore, it is not possible at this stage to assess: (a) the financial management capacity of the FMA; (b) and the compliance of its financial management system with Bank procedures. The mains functions of the FMA include the planninghudgeting, the accounting and reporting, management of special accounts, control and capacity building. The TORS of the Fiduciary Agency have been prepared. This FMA would be evaluated yearly partly according to how successful it has been in ensuring that the MOH s DAAF can now implement certain functions, in order to ensure a phasing out of the FMA. At decentralized level (DRS, CS, DPS), minima financial management tools are in place but need to be improved. In addition, decentralized health structures would receive funds based on a performance contract (agreement) they would sign with MOH, however only those structures which would have undertaken a basic financial and procurement course would be able to receive funds from the MOoH. The project financial and accounting document is being finalized, the draft is already available. Procurement Aspects: The Fiduciary Management Agency (FMA) would be responsible, along with the DAAF of the MOH for procurement of most items. Agreements with the 198 Health Centers Committees would allow those committees to procure current small items which are usually included in recurrent expenditures (gasoline, cleaning and maintenance products, etc.). Hiring of local personnel such as contracted midwives would also be done by the central level on behalf of the local level. The first 10 agreements to be signed with health centers, the first 10 contracts to be signed with the private sector, the first 10 to be signed with prefectoral hospitals, the first 10 to be signed with DPS and the first to be signed with DRS, would require prior non-objection from the Bank. There would not be any new construction in this project, as previous IDA-financed projects concentrated on this aspect but the project would finance some renovation of health posts that are in a dilapidated state. These renovation would be managed through community participation. 4. Social This project would contribute to reducing inequities in Guinea as it targets the 18 poorest prefectures of the country. Such targeting is unprecedented in Guinea and should result in dramatic changes for the life 11

18 of the poor people living in those prefectures, if the project is well implemented. Results from the DHS will be broken down by income quintile to assess progress on the equity front. 5. Environment This project falls under environment category B. A Medical Waste Management Plan was prepared by the Government and reviewed by the Bank in Its quality and content were satisfactory; and the report has been disclosed in country and in the Bank Info shop twice. The project is not expected to have substantial adverse environmental effects. The environmental risks pointed out by the report include particularly: (i) the inappropriate handling and disposal of medical waste by untrained staff; (ii) the inadequate management of the respective disposal sites in urban or peri-urban areas where domestic and medical waste are often mixed; and (iii) disposal of some waste on open sites to which anyone can easily have access and manipulate waste with no safe precautions. The plan that has been prepared proposes measures to mitigate these potential risks, including clear institutional arrangements to implement and monitor those measures. The plan also includes a costed awareness and capacity building framework to effectively implement the plan, and an implementation schedule. The action plan proposed by the Medical Waste Management Plan is being partly implemented in the capital city s main hospitals with the help of the European Union as well as the Bank-financed HIV/AIDS (MAP) project. This project, under its Institutional Strengthening component, would support the improvement of medical waste management in hospitals at the prefecture level, health centers at the district level, and health posts in rural areas. It would finance the provision of (i) incinerators as necessary, (ii) safety equipment for the personnel of those health facilities, (iii) training for hospital staff, and (iv) public awareness campaigns. The environmental benefits would be monitored by independent experts commissioned by the Task Force, with the involvement of the Ministry of Environment. 6. Safeguard policies Safeguard Policies Triggered by the Project Yes No Environmental Assessment (OP/BP/GP 4.0 1) [ XI [I Natural Habitats (OP/BP 4.04) [I cx 1 Pest Management (OP 4.09) [I [x 1 Cultural Property (OPN 11.03, being revised as OP 4.11) [I [x 1 Involuntary Resettlement (OP/BP 4.12) [I [x 1 Indigenous Peoples (OD 4.20, being revised as OP 4.10) [I [x 1 Forests (OP/BP 4.36) [I [x 1 Safety of Dams (OP/BP 4.37) [I [x 1 Projects in Disputed Areas (OP/BP/GP 7.60)* 11 [ XI Projects on International Waterways (OP/BP/GP 7.50) [I [x 1 li By supporting the proposedproject, the Bank does not intend to prejudice the final determination of the parties claims on the disputed areas 12

19 7. Policy Exceptions and Readiness 9 This project complies with all applicable Bank policies. 9 Disclosure requirements are met. 9 The procurement documents for the first year s activities are complete and ready for the start of project implementation. 9 The project Implementation Plan for the project has been appraised and found to be realistic and of satisfactory quality. 9 One of the particularities of this project is that it would not have a project coordination unit per se, but will be integrated within the M OH existing structure and would use existing MOH civil servants. 9 The Ministry of Public Health has a well established monitoring and evaluation system which has proven to be efficient and which will be used for project monitoring and evaluation purposes. The following items are missing and are discussed under credit effectiveness condition: Project Implementation Manual and Financial, Administrative and Accounting Manual have been adopted by Government and satisfactory to IDA Counterpart funds released in a commercial bank Fiduciary Management Agency has been selected Extemal auditors have been selected Performance-based contracts, in form and substance satisfactory to IDA, have been concluded with at least 10 health structures in the 18 targeted prefectures. 13

20 Annex 1: Country and Sector or Program Background GUINEA: HEALTH SECTOR SUPPORT PROJECT Table 1: Natural Regions sorted by poverty (poverty based on demographic and health survey wealth index analysis) Region Poorest 2 d Poorest Middle 2 d Richest Richest Income quintile quintile quintile quintile index (mean) Central Guinea Upper Guinea Forest Guinea Lower Guinea Conakrv Guinea s context Some areas of Guinea are poorer than others as the table below shows. Those areas would be targeted first in order to have a more rapid improvement in indicators. Table: Classification of Regions by Poverty Levels Lower Central Higher Forest Total Urban Rural Guinea Guinea Guinea Guinea Conakry Percent urban Dooulation Population density 29 n.a. n.a Access to safe water Percent poor 40 n.a. n. a Percent with less than US Depth of poverty (gap between Share o f National Poverty) (%) Per capita expenditure ( n.a. n.a n.a. Share of food in total spending Source: UNPOP 1998, RGPH, General Population and Housing Census 1996, Comprehensive Consumption Budget Survey , Household Consumption Survey. Taken from the Guinea Country Status Report, In the same vein, health indicators also indicate inequity problems as the table below shows: Table: Household Health Behaviors : Comparison by Place of Residence and by Region Lower Central Higher Forest Indicators Country Urban Rural Guinea Guinea Guinea Guinea Conakry Child health Median duration of breast feeding % of newborns < 6 months old on exclusive breastfeeding

21 ~ Existing % of newboms age 6 to 9 months breastfed without additional semi-solid supplements a. % of use of private health services in cases of infectious respiratory disease of a child age of 5 or less b. % of children mos. With completed vacc. before age of 1 % Children mos. with no immunization % of children with diarrhea in previous two weeks and were offered increased fluids and continued feeding (specifically breast feeding) by caretaker. c. ORT: % of children with diarrhea who received ORT, rehydration preparation or increased liquids d. % of mothers with under 5 children with knowledge of TRO and nutritional need during diarrhea episodes e. ARI : % of children with cough and rapid breathing who received medical treatment Reproductive Health f. % of pregnant women with at least one ANC g. % of pregnant women having delivered with physician, nurse or midwife assistance h. % of deliveries without assistance % of adult men using condom regularly Use of Modem Methods of Contraception Communicable disease % of women without knowledge of any means for HN prevention % of men without knowledge of any means for HN prevention Kon-communicable diseases % of households consuming iodized salt Source: DHS * As can be seen from the following table, reaching the MDGs will require substantial effort: situation Objectives Date Value of indicator Medium term Long term Crude death rate (%) (2005) 9 (2010) Infant mortality rate (%) (2005) 50 (2010) Matemal mortality rate (%) (2005) 200 (2010) HN seroprevalence rate (%) < 5(2005) 5 (2010) Source: Country Status Report, World Bank, 2003 What would be done by the Bank in the sector by &I Bank operations The sectoral approach is selected as the best suited way to achieve the above objectives. This approach would facilitate movement away from the project approach, previously used in Guinea, to a future budgetary support approach, would strengthen the sector in preparation for the PRSC, and would reduce the need for a PCU. The project would finance activities addressing the following issues, many of those activities would be integrated into the PRSC as this instrument becomes available, and are built on the achievements of the PACV and PRCI: 15

22 . Strategies to build increasingly sustained financing of public health interventions for the poor: Increase government financial commitment to health as current overall expenditures on health does not cover the cost of both public health and basic curative care interventions (PRSC) Ensure efficient fee collection at hospital level: user fees, local insurance systems. Coordinate donor funding as part of the health development plan... Strategies to increase the efficiency of the provision of essential interventions: Costing of essential clinical and public health services Reallocation of resources towards primary and essential secondary care (such as emergency obstetric services) and non salary recurrent costs (PRSC) Strengthening of decentralized management at district level (parts can be done through PACV) Strengthening capacity in budgeting and expenditures tracking at the central level (PRSC) Develop autonomous management capacity of hospitals Development of a transparent district accounting system (PRCI) Optimization of the use of locally generated resources by local retention of the resources and participatory management Publicizing the budgets of each health infrastructures. This is expected to increase transparency and better use of resources by government workers. Strategies to ensure the provision of a package of essential interventions to the poor: This package is to be cost effective, affordable and have the public goods character. This basic package includes child health interventions (EPI, breast feeding promotion, micro-nutrient supplementation, IMCI including ARI, diarrhea and malaria case management, neonatal care), reproductive health interventions (Family planning and safe deliveries, STIs ) as well as control of communicable diseases (TB, malaria ). It is to be complemented by a package of support services from local, regional and national hospitals, especially regarding maternal and child health. To ensure the coverage of the poor with that package of essential services the strengthening institutional capacities and systems e.g., Development of a legal and regulatory framework for decentralization PRCI) (in coordination with Support phased decentralization of management to local health authorities by building the capacity of district health teams and providing them with block-grants against health plans (parts of this could be integrated into the PACV) Rationalize training institutions to ensure an appropriate skill mix oriented towards the effective provision of the essential package of services. Improving mechanisms to ensure continuous availability of essential commodities including pharmaceutical procurement and management, distribution of drugs, management of supplies in peripheral facilities and establishment of drug revolving funds Assess current physical access to the system by inventorying and mapping health facilities Monitoring of the performance of the districts based on their achievements against health plan and objectives 16

23 Annex 2: Major Related Projects Financed by the Bank andlor other Agencies GUINEA: HEALTH SECTOR SUPPORT PROJECT THE BANK S INVOLVEMENT IN THE HEALTH SECTOR IN GUINEA: Multi-Sectoral AIDS Project (MAP), Grant no. H0140-GUI, became effective in March 2003, for SDR15.4 millions. Its main objective is to limit and reverse the trend of the HIV/AIDS epidemics by preventing new infections. The latest IP and DO ratings are both S. Population.and Reproductive Health Project, Credit GUI, started in 1999 and closed in December 2003, for SDR 15 millions. Its main objective was to provide support to the Government of Guinea in its efforts to improve the well being of the population by preventing the risks related to reproductive health, preventing and reducing the occurrence of illnesses among vulnerable groups. Its final IP and DO ratings were U. Health and Nutrition Project, Credit No GUI, started in 1995 and closed in March 2002, for SDR 17.4 millions. Its main objective was to contribute to the improvement of the health status of the population in Middle and Lower Guinea and in particular of its most vulnerable groups. Final IP and DO ratings were S. OED ratings not yet available. Community Support Program, Credit no GUI, effective November 1999, for SDR Latest IP and DO ratings were S. Capacity Building for Service Delivery Project, Credit no GUI, started in May 2000, for SDR13.8. Latest IP and DO ratings were U. This project is presently under suspension. Project for the Development of Health Services, Credit no GUI, started in 1988 and closed in 1993, for SDR 8.5 millions. OTHER DONORS PRESENT IN GUINEA AND THEIR MAIN AREAS OF SUPPORT: European Union: is a major partner, mainly involved in: M&E, Research, Budget support (TA), Decentralisation (T.A., no investment), Health Centers, and Drugs Contribution to the PNDS: 21 millions EURO GTZ provides T.A. in three regions in the following domains: MURIGNmutuelles; Budgetary decentralization; Quality of care; Performance Contest and Quality insurance; Community capacity building; Vaccination supply; Health mapping Contribution to the PNDS: millions GNF Japan: Vaccination supply; Treated mosquito nets Contribution to the PNDS: millions GNF WHO: Vaccination supply; Development of national policies Contribution to the PNDS: millions GNF UNICEF: Vaccination supply; Vitamin A Campaign; HIVIAIDS: PTMC, ARVs, Reagents Contribution to the PNDS: GNF 17

24 UNFPA: Contraceptives Contribution to the PNDS: millions GNF USA: Contraceptives; Community capacity building; Quality of care Contribution to the PNDS: millions GNF The African Development Bank: Decentralization; Primary health care Contribution to the PNDS: millions GNF France: Technical Assistance. The European Union, the GTZ, and UNICEF participated in all the preparation missions. 18

25 Annex 3: Results Framework and Monitoring GUINEA: HEALTH SECTOR SUPPORT PROJECT Results Framework PDO Reduce maternal and infant mortality in the 18 targeted prefectures Intermediate Results Component One: Strengthening Health Services Sub-component A: Improve quality of care in 250 health posts, 200 health centers, 2 improved health center and 18 prefectoral hospitals Component One: Strengthening Health Services Sub-component B: Increase demand for health services Component One: Strengthening Health Services Sub-component C: Quality Insurance Outcome Indicators 12,000 death o f pregnant women and 27,500 death o f children less than 1 year of age have been avoided in 18 prefectures by Results Indicators for Each Component Component One, sub-component A: a. 250 health posts provide a complete IMCI package b. 200 health centers provide basic emergency birth delivery services C. 18 prefectoral hospitals and 2 improved health centers provide full emergency birth delivery services d. assisted delivery increases from 42% in 2004 to 65% in 2010 e. Vaccination coverage of children under 1 for DTCP3 increased from 70% in 2004 to 90% in 2010 f. Proportion of caesarian sections increases from 1.8 in 2004 to 5% in % of pregnant women who benefit from TPI (malaria prevention treatment) from 0% in 2005 to 80% in 2010 Component One, sub-component B: a. 130 new health mutuals created by 2011 b. pilot project for ownership of health centers by communes and CRDs evaluated by 2011 Component One, sub-component C: a) 100 health centers have participated in the selfevaluation process by project mid-term (2008) Use of Outcome Information 'rovide guidance to policy makers for trategic formulation for effective health esource allocation Use of Results Monitoring Zomponent One: 3etter inform implementers and 'Inanciers of intervention where gaps are md how to maximize resources itilization for subsequent years of xoject implementation Component One: Better inform implementers and financiers of intervention where gaps are and how to maximize resources utilization for subsequent years of project implementation 19

26 Component Two: Capacity Building Improved monitoring of the Five- Year Plan The MOH is ready for budget support b) 200 health centers (cumulative) and prefectoral hospitals and 2 Improved Health Centers Component Two: a. b. C. d. e. 100% of health infrastructures supervised by next-in-line supervisor on a regular basis by 2008 Joint annual review of the Plan from end-2006 onward % o f budget for health center reaching them increased from 30% in 2002 to 70% in incinerators have been purchased and installed by medical health personnel have been trained in medical waste management by Component Two: All conditions for transition to budget support met by 2010: a. Satisfictor y yearly evaluations of the Five- Year Plan; b. 70% of national budget allocation to health centers reaches them; C. MOH has executed 70% of its national budget allocation from 2006 onward; d. Satisfactory financial management audits for at least the last two years; e. Project objectives have been achieved according to ICR; f. Number of contracts with private sector increases from 0 to 50/year by 2011 g* 90% of contracts with private sector have been executed by 2011 Component Two: Better inform implementers and [inanciers of intervention where gaps are md how to maximize resources itilization for subsequent years of sroject implementation Component Two: Better inform implementers and financiers of intervention where gaps are and how to maximize resources utilization for subsequent years of project implementation GRADUATING CRITERIA TO A PRSC One o f IDA S objectives in financing the National Health Program is to help the MOH become ready for budgetary support. To succeed in this transition to budgetary support, some eligibility criteria have been defined and were agreed to during the March 2004 preparation mission : 20

27 AT THE MACRO ECONOMIC LEVEL: A PRSP which (i) shows the priority given to the health sector, (ii) provides impact objectives as they relate to the MDGs; (iii) is monitored in a participatory manner; AT THE HEALTH SECTOR LEVEL: A complete five-year plan (with all the activities and available financing and its sources), monitored yearly (verified by the annual review) ; More than 70% of the national health budget given to the health centers reaches the health centers (verified by a health expenditures tracking survey) ; The MOH executes more than 70% of its budget by the end of the fiscal year (December 3 1); Adequate financial management by the MOH (verified by an annual audit) ; Decreased parallel payment practices in hospitals (verified by a survey); 0 Results of the Health Sector Support Project are attained (verified through surveys and regular project supervision, and the project Implementation Completion Report (ICR)). 21

28 5 0 B P t t 'E e e! E.- e (I) m c 8 e! e 2 B s z r s I I 1 M E L 0.I Y.- i m Y I 2 e 3 E & 9 4 a2 L L m Y L I m \o I 0 0 N s Q B N k 2 s s m k 2 0 E:

29 x 5 - c 2 x e > m N 0 r. h 3 T 3 r. 0 k c a - 0 m - in 0 3 n m

30 Activity Monitoring and Evaluation. Activities on any level would be monitored following structured reporting and assessment forms and procedures. Given the program s large scope of interventions and decentralized nature of activities, it would be necessary to incorporate a coherent and consistent set of indicators into all contracts/agreements funded by the project. For example, the health centers or prefectoral hospitals would be required to submit their plans following the logical framework outline linking inputs, process, outputs. Agreements/ contracts would be performance-based and would thus identify all yearly indicators which those front-line health structures plan on achieving. These indicators would be compiled and aggregated in the annual report of the Task Force. Outcome and Impact Monitoring and Evaluation. Another aspect of the M&E system would be the monitoring of the outcome and impact; this would be done by a Demographic and Health Survey at the beginning and end of the project. In addition, data on deaths avoided would be calculated through operational research contracted to a specialized institution which would use DHS estimates as well as health structures records on coverage. Quality of services would be checked yearly based on a simple checklist which describes the standards expected and which would be designed with the help of GTZ. Such quality check would be contracted out to consultants. Smaller surveys and operations research might also be needed every time a problem is identified and its solution is not obvious. Financial Monitoring and Evaluation. Lastly, financial management monitoring of the utilization of resources and funds by the public sector, private sector and civil society would be combined with program monitoring to provide a basis for cross checking financial and activity data and establishing the relation between disbursement and activities. Audits would be carried out by the FMA as well as external auditors, at all levels. A yearly health expenditures tracking survey would provide information on how much the MOH is able to improve on the national budget s allocation and utilization of resources by different levels. 24

31 Annex 4: Detailed Project Description GUINEA: HEALTH SECTOR SUPPORT PROJECT TARGETING The project would target the 16 poorest prefectures in the country (as identified by the Poverty Map), and 2 prefectures (Kissidougou and GuCckCdou) which have been particularly hit with a difficult refugees situation, as listed below: LIST OF PREFECTURES TARGETED BY THE PROJECT Prdfectures Administrative Region Natural Region Nbr. Of health centers Nbr. Of existing health mutuals (mut.) or MURIGA (mur.) Koundara Gaoual TklimelC Bok6 Bok6 Kindia Moyenne Guinee C Y Basse GuinCe mut. Mali Koubia Tougue Lklouma Dalaba Pita Labe Labe Labe Lab6 Mamou Mamou Moyenne Guinee C Y C Y C Y C Y mut.+2 mur 1 mut. 2 mut. 1 mut. 2 mut. 3 mut. Dinguiraye Dabola Kissidougou GuCckCdou Beyla Faranah Faranah Far anah N'ZCrCkore N'ZerCkork Haute GuinCe C Y Guinke Forestibre C Y C Y mut. 2 mut.+6 mur. 2 mut.+l mur. 1 mut. 3 mur. Siguiri Kouroussa Mandiana KerouanC Total : Kankan Kankan Kankan Kankan Haute Guin6e C Y C Y C Y mur. 8 mur. 8 mur mut.+33 mur. 25

32 PROJECT COMPONENTS P Component I: Strengthening Health Care Services (US$18.99 million) This component would help strengthen health posts, health centers and hospitals in the 18 selected prefectures to give quality services to at least 1 million pregnant women and 933,000 kids less than one year of age. The package of health services that would be reinforced are those for prenatal care, normal and emergency delivery for women, and those o f the integrated management of childhood diseases for children. 0 Sub-component A: Oualitv of care: investments would be made in particular to (i) reinforce the chain of care for at-risk deliveries, starting with early identification by village traditional birth attendants; (ii) improve the norms and adherence to the norms for basic as well as emergency birth delivery in public and private health centers; (iii) improve emergency birth delivery care at the higher levels of the network, namely in Centres de SantC AmtliorCs, private clinics and prefectoral hospitals; (iv) increase utilization of family planning services and of IMCI activities, namely EPI, diarrhea control, acute respiratory illnesses, malaria, nutrition; (v) improve access to care by improving the referral system via radio and ambulances; (vi) implementation of the existing on-the-job master plan would be financed, along with assistance to the training of more midwives. Since the new mid-wives would not be available for three years, contracting of retired midwives would be implemented to fill the gap especially in rural areas. This sub-component would be implemented mainly through performancecontracts signed between the MOH and health centers and district hospitals (agreements). Those agreements would allow financing of the following expense categories: Agreements to be Expense financed but items signed with: I bought by the central level Health Center I salaries of contractuals (midwives or other qualified personnel) vehicles (moto, bike) Basic Emergency Obstetrical equipment Child care equipment Prefecture Hospital Salaries of contractuals. Ambulance Radio-communication equipment Emergency Obstetrical equipment Expense financed and money goes directly to the local level Bonuses for advanced strategy missions Training of village midwives Renovation and Maintenance of infrastructure & of equipment Supervision of health centers. expenses Gasoline for emergency referral cases Training of health center and health post staff in antenatal care, all emergency obstetric care, child care 26

33 Prefectoral Directorates Health of Supervision vehicle Supervision fees and bonuses Maintenance of supervision vehicle. Semestrial coordinating meeting of CTPS in the health centers 1. Maintenance of equipment Agreements with Health centers and Prefecture hospitals would be signed with their management committees, as long as those committees produce the proof that they are organized as a private entity such as an association. Details on the implementation of the quality of care sub-component: In the project s cost tables, the average cost of a training session was calculated from the estimate of total cost of the session divided by the number of participants. The total cost of a training session includes per diem (based on official national references) paid to the participants, reimbursement of travel expenditures, logistics for organization, allowances for the trainers. During the project each training session cost would be estimated on this basis. Validation of the training session for Emergency Obstetrical Care (EOC): workshop with the 6 best national obstetrical care physicians and 4 members of the task force during five days to update the content of the EOC training session. Workshop for supporting the training of trainers with international consultant: this workshop with the six participants of the previous workshop would be assisted by an international consultant to elaborate the best pedagogical approach and customization of contents in regard to the profile of training participants. The consultant who would have an on field background would also come from a country having achieved good results in maternal mortality. Training of trainers: The trainers would be members of the task force from the 18 prefectures. 36 trainers would be trained in 2 sessions (18 per session) with the support o f 3 facilitators (from national team having elaborated the content of EOC and attended the previous workshop). Training; midwifes and health workers to EOC: a first session of training and knowledge up dating would be organized for all the participants of EOC services (first line and referral) from the 18 prefectures. Midwifes and health workers would follow the same session for everybody to share a common ground. Each training session of five days would be organized with 20 participants gathered at regional level. The trainers would be members of the task force. Planning and organizing EOC training sessions would have to be in accordance with the schedule for pediatric care training because the same health workers (except midwives) would attend both of these sessions. In relation with the pediatric care (PCIM) all health workers should be able to undertake all essential activities for mother and child. All health workers should be able to hold any of the working 27

34 stations or several o f them when alone in the health care center. In many areas there is not enough population to justify three hll working stations in each health care center. More over each health worker involved in EOC would have to make an intemship in a referral service to improve its clinical ability. These intemships would be dispatched in such a way they would favor participation to a high number of birth and a better understanding of adequate referrals. Over all internship should improve the links between first line and referral teams. After a year, a second session of five days would be organized for the health workers. This session would allow to come back on major weaknesses pointed out during supervision and to share lessons from effective practice. This session would be an addition to supervision and bring further support to health workers involved in EOC. These different training sessions make up the core of the project bringing up the minimal required skill to give credit to health worker through effective action. Effectiveness would be measured by the evolution of index of maternal and infant mortality. Training the traditional birth attendant (TBA): TBA would be provided a kit with all what is necessary for attending a normal birth. They would also participate to a training on EOC to be better involved in the follow up process. Better skill and understanding when there is a need for referral should result from this training. This training would be done by the prefectoral members of the task force, providing same level of skill to TBA within a same prefecture. It is not a good alternative to ask health center health workers to be trainers, there skill is not sufficient for such a task and there are not enough midwifes to give them such a mission while priority should be on supporting clinical activities. Hiring midwifes at local level (CRD): quality of care for expectant women relies on a first consultation given by a midwife (Who has better capacity than a health worker to identify maternal risks) who should be able to follow up all women under risk. The shortage and the uneven dispatching of midwifes in the country would not make it possible to have a midwife in each health center. Nevertheless to improve dramatically quality of care there is a need to have more midwifes in most populated rural areas. Hiring 50 extra midwifes at local level (CRD) should be possible in regard to the potential market response. o Sub-component B: Community mobilization: investments would be made mainly to:. Support the existing successful MURIGA system, which is a health mutual system implemented during the previous World Bank financed project, and which provides coverage mainly for women s health related to birth. Health mutuals, which cover more risks than the MURIGAs, would also be created.. In order to strengthen the Government s policy for decentralization, some health centers would be managed by communes and CRDs, starting with a pilot activity in six prefectures the first year. The evaluation of this pilot would help decide how to extend it to the other 12 prefectures. Agreements would be signed with those urban and rural communes rather than with the health center s management committee. 28

35 . Re-energizing of health committees around health centers would be done by ensuring that health centers who serve poor populations receive their govemment allocation - as they only receive 30% now according to the Health Expenditures Tracking Survey carried out in In order to improve governance, the publication of the budget received by each health structure and how the money was spent would be done throughout the country so that the population is aware and government officials are accountable to them. o Sub-component C: Oualitv Insurance: the MOH has taken the option to improve utilization of health services by strengthening their quality. Such a system has been put in place with the help of GTZ in two prefectures. Evaluation of this pilot was carried out end of 2004, preliminary evidence seems to indicate that this approach is successful. Lessons leamt from the evaluation would be taken into account and based on this evaluation, the project would help extend this improved system to all 18 targeted prefectures. Following a self-evaluation, health structures decide on a plan to improve six basic aspects of health care: technical skills, client satisfaction, continued training, community participation, management of the district, financial management. The best plans would be rewarded. Then each structure plans its annual operation plan based on its diagnosis. The project would help finance both the self-evaluation process as well as parts of the annual operation plan. GTZ would be hired as technical assistance on a sole source basis to strengthen the MOH and help it manage this component. This decision was made since GTZ is already doing so for other prefectures and since the German govemment would co-finance in a parallel way some of the technical assistance required for the extension to the 18 targeted districts. 9 Component 11: Institutional Strengthening (US$8.37 million) Investment would be made to increase coordination and monitoring and evaluation. 0 A Pilot Committee for the Five Year Plan would be put in place along with a Task Force for the project. The Task Force would focus on facilitating technical implementation of the project and ensuring its objectives are reached, and the credit would finance the necessary supervision costs, studies, operations research, workshops, study tours in the Region. With the assistance of the National Quality Council, the Task Force would be responsible for the self-evaluation of the quality of health structures. 0 The credit would help finance integration of maternal mortality into the health information system, which involves mainly some technical assistance and workshops. 0 The project would strengthen the MOH s Administrative Unit (DAAF) and decentralized units in order to prepare them for budgetary support. This would be done first by hiring a Fiduciary Management Agency which would transfer certain competencies each year to the DAAF as part of its contract, also a financial audit would be carried out on those decentralized structures, and they would all receive assistance to meet certain basic requirements in terms of financial management and contract management. 0 The project would strengthen the MOH structure in charge of developing the national insurance Scheme therefore it would finance the recurrent costs of this unit, its logistical 29

36 support (transport and computer system), technical assistance; workshops, and study tours in other African countries. a A yearly health expenditures tracking survey would be undertaken to see if there s any improvement. Finally, the purchasing function of the MOH would be improved in terms of public-public contracting between the MOH and Municipalities or Rural Development Committees (CRD) (agreements), and between the MOH and private service providers (contracts). Finally, to complement other financing (UNFPA in particular) which are helping build a new Reproductive Health Training and Research Center in Conakry, the credit would help finance equipment of that center. a This component would support the improvement of medical waste management in hospitals at the level of prefectures in the regions; health centers at the village level, and health posts in rural areas. This support would include the provision of (i) incinerators as necessary; (ii) safety equipment for personnel working at hospitals at the levels of the prefectures, health centers, and health posts; (iii) training in medical waste management for health care personnel at the afore-mentioned hospitals; and (iv) public awareness campaigns explaining the dangers of medical waste to public health and the environment. 30

37 Annex 5: Project Costs GUINEA: HEALTH SECTOR SUPPORT PROJECT Local Foreign Total Project Cost by Component and/or Activity US$ million US$ million US$ million Component I: Strengthening Health Services , A. Am6liorer la couverture et de la qualit6 des soins B. Mobiliser la participation communautaire C. Assurer la qualit6 des soins 2.14 Component 11: Institutional Strengthening A. Assurer le suivi et Evaluation B. Bureau de Gestion du Projet C. Renforcer les capacitds en gestion programmatique D. Renforcer les CapacitCs de gestion financibres E. Renforcer les capacitks de contractualisation F. Assurer la suivi des depenses de sante G. Renforcement d'un systeme national d'assurance maladie Refinancement de I'Avance PPF Total Baseline Cost Physical Contingencies Price Contingencies Total Project Cost Total Financing Required 'Identifiable taxes and duties are US1.1 million, and the total project cost, net of taxes, is US$26.7. Therefore, the share of project cost net of taxes is 96%. 31

38 ANNEX 6 IMPLEMENTATION ARRANGEMENTS One of the particularities of this project is that there would not be any project coordination unit per se. The coordination would be done by the Secretary General of the MOH, who would have a small team at his service to manage the IDA credit, namely a coordinator, an accountant, a procurement person, a secretary, in addition to the services of the contracted Fiduciary Management Agency (FMA). The FMA will, every year, have to transfer some responsibilities to the DAAF of the MOH in order to build capacity. Those tasks to be transferred are mentioned in the contract the MOH would sign with the FMA. All the contracts management would be done through the DAAF. The DAAF set up a team to follow-up on all the health service delivery agreements written with health centers committees, and all contracts with the NGOs, health mutuals or the private sector. In addition, a health program task force, made of the concerned directors and main technicians of the MOH would ensure that the project is executed within the national health program. This task force would coordinate the technical aspects of the project and be in charge of managing, mainly through contracting out, all necessary training, quality control, evaluation and operations research. The project would help finance some recurrent costs for this task force, namely recurrent expenditures when they go on supervision in the target areas, as well as their periodic retreats for stock-takmg. A sub-set of the task force would be in charge particularly of ensuring the project is well executed, this committee would be comprised of the Director of Hospital Services and the Director of Reproductive Health, among others. In terms of quality control, the task force would have the National Quality Council at its service. This Council, already set up with the help of GTZ, would be reinforced by the project. The Task Force would meet regularly every month at the beginning of the program to ensure close monitoring. It would be fed data from the National Quality Council, from the Project Committee, from the Secretary General s office and the DAAF. levels: The following table shows the responsibilities of the different actors at the different */ Payment is made out directly to the structure of the agency implementing the activity. WPA = Work Program Agreement; SG = Secretary General of the MOH; DAAF = Financial Management unit of the MOH. 32

39 Annex 7: Financial Management and Disbursement Arrangements GUINEA: HEALTH SECTOR SUPPORT PROJECT 1 - Summary of the Financial Management Assessment The Ministry of Health (MOH) which would be the implementing agency for the project does not have capacity and adequate financial management system in place. The MOH would therefore contract a Fiduciary Management Agency (FMA) as a financial and procurement management firm which would have the responsibility for the project s financial and procurement management under the supervision of the Head of the Directorate of Administrative and Financial Affairs (DAAF) of Ministry of Health. The FMA is yet to be recruited. Therefore, it is not possible at this stage to assess: (a) the financial management capacity of the FMA; (b) and the compliance of its financial management system with Bank procedures. The main financial management functions of the FMA include the establishment of the financial management system for the project, planninghudgeting, accounting and reporting, management of special accounts, control and capacity building. This FMA would be evaluated yearly according to how successful it has been in ensuring that the MOH s DAAF can now implement certain functions, in order to ensure a phasing out of the FMA. The FMA s procurement functions are described in Section B. of Annex 8 (Procurement) of this document. The TOR of the Fiduciary Agency have been prepared and the recruitment process launched. The signing of a contract with the selected FMA is a condition of credit effectiveness. At decentralized level (DRS, CS, DPS, Prefecture Health Center), the minimum financial management tools are in place but need to be improved. This would be done when the project become effective. Only decentralized heath structures which would have undertaken a basic financial and procurement course would be able to receive funds from the project coordination. The project financial and accounting manual is being finalized, the draft is already available. 2 - Audit Arrangement The Government would recruit an independent auditor acceptable to IDA. The audit would be conducted in accordance with auditing standards acceptable to IDA and under terms of reference acceptable to IDA. The auditor would be responsible for the annual audit of project financial statements, and provide an opinion on the (i) project consolidated accounts; (ii) transactions on special accounts and Project account; and (iii) statement of expenditures and the eligibility of the expenses withdrawn on the basis of SOEs. The auditor would also provide a management letter. The audit report shall be submitted to IDA within six months of the end of the project fiscal year. during project implementation. 3 - Disbursement Arrangement The FMA would be entrusted with the project s overall financial management and reporting through a contractual arrangement with the MOH. Funds would be disbursed in accordance with categories of expenditures and disbursement percentages, as shown in Annex 1 of the Development Credit Agreement. Disbursements would be made according to procedures outlined in the Bank s H Manual of disbursement procedures D, The standard disbursement procedures, including replenishments of the special account advances, direct payments, Special Commitments and the reimbursement of pre-financed expenditures would apply. Report-based disbursements would not be used for this project. However, the project would submit financial monitoring reports (FMRs) to IDA within 45 days of each quarter. 33

40 Allocation of loan proceeds Expenditure Category Amount In SDRs million Financing Percentage 1- Goods (incl. drugs) 2- Civil Works (renovations) 3- Consultants Services, incl. audits 4- Training, incl. Study Tours 5- Subproject Grants 6 - Work Program Agreements (Goods and Services) 7- Incremental Recurrent Cost 8. PPF 9- Unallocated 3,9,80, ,000 2,320,000 3,320,000 1,680,000 1,000, , ,000 2,650, % of foreign currency and 80% local 80% 80% 100% 100% of amount disbursed 100% of amount disbursed 90% Amount due Total 1 16,600,0001 I I Note: The term operating costs means the incremental expenses incurred by the MOH on account of project implementation, management, and monitoring, including: office space rental and utilities, office supplies, bank charges, communications, vehicle operation, maintenance, and insurance, building and equipment maintenance costs, travel and supervision costs, and advertising costs, but excluding salaries, honoraria, and fees of members of the Borrower s civil service. Flow of funds Except for any direct payments, funds from the Credit would flow trough Special Accounts A and B denominated in US$. Funds from SA-A would flow directly to the GNF accounts of communities to finance grants for subprojects (see category 5, above) and CS, DPS and DRS and prefecture hospitals for the implementation of their respective Work Program Agreements (see Category 6, above). Funds from SA-B would be managed by the Project Coordination Unit and the FMA for the payment of any eligible expenditures other than those eligible under SA-A (categories 5 and 6, as shown in the above table) Fund management would follow transparent procedures, as detailed in the project financial and accounting manual. 4 - Special Accounts The project would open two special accounts A and B in US dollars in a commercial bank acceptable to IDA to facilitate project implementation. Special Account A (SA-A) will be used exclusively for transferring funds to DRS, DPS, Health Committees and Rural Communities. Disbursements would be made based on (i) Financing agreements signed between the communities and the MOH and (ii) Work Program Agreements signed between the DRS, DPS, Health Committees and the MOH. The communities will receive disbursements in one or two tranches, in accordance with their Financing Agreement, while DRS,DPS and Health Committees would receive a cash advance covering a period of no more than sixty days to finance expenditures related to supervision, training, maintenance and gas purchases under their Work Program Agreements. The PIU would replenish the advances to 34

41 the DRS, DPS and Health Committees based on the submission of Statement of Expenditures (SOEs). Disbursement of the first tranche to a community will be made based on a copy of the Financing Agreement, while any further tranches will be disbursed based on a technical certificate o f progress and a simplified financial report. All of the documentation supporting the expenditures would be maintained in the respective DRS, DPS, Health Center or rural Communities. Any larger payments related to contractual salaries or the purchase of equipment on behalf of DRS and DPS would be financed by the Project Implementation Unit in Conakry The authorized allocation for expenditures eligible under categories 5 and 6 would be US$0.5 million and would cover approximately four months of eligible expenditures in accordance with the Work Program Agreements submitted by decentralized heath structures and the volume of anticipated Financing Agreements signed by communities. Upon credit effectiveness IDA would deposit the amount of US$0.25 million which represents 50 percent of the authorized allocation, into Special Account A. The remaining balance would be made available when the aggregate amount of withdrawals for eligible expenditures under Special Account A shall be equal or exceed the equivalent of SDR 0.7 million. Special Account B (SA-B) would be used exclusively to finance all other project expenditures. The authorized allocation would be US$1,5 million and would cover approximately four months of estimated eligible expenditures. Upon credit effectiveness IDA would deposit the amount of US$0.75 million into the Special Account. The remaining balance would be made available when the aggregate amount of withdrawals from the Credit account plus the total amount of all outstanding special commitments entered into by the Association shall be equal to or exceed the equivalent of SDR 5 million. The Special Account would be used for all payments inferior to 20 percent of the authorized allocation and replenishment applications would be submitted monthly. Further deposits by IDA into the Special Account would be made against withdrawal applications supported by appropriate documents. 5 - Uses of Statements of Expenses (SOEs) Disbursements for all expenditures would be made against full documentation except for items of expenditures under: (a) contracts for consulting firms in amount inferior to US$lOO,OOO equivalent; (b) contracts for individual consultants in an amount inferior to US$50,000 equivalent; (c) contracts for goods and works in an amount inferior to US$150,000; (d) grants for subprojects, Work Program Agreements, training and operating costs which would be claimed on the basis of statements of expenditures (SOEs). All supporting documentation for SOEs would be retained by the Project Implementation Unit, DRS, DSP, the Health Committees and the rural communities and kept readily accessible for review by periodic IDA supervision missions and external auditors. 6 - Counterpart Funds Total counterpart funds are estimated at US$2.8 million including taxes for US$l. 1 million over a five-year period. The Borrower would open a Project Account in GNF in a commercial Bank in accordance with terms and conditions acceptable to IDA, in order to receive the compensation fund necessary to cover the part of the Borrower with respect to the total cost of the project and under the different categories whenever necessary. Before the effectiveness of the project the Borrower would deposit an initial contribution of GNF 350 million (approximately US$120,000) in the Project Account. Other deposits would be made quarterly to complete the yearly counterpart funds requirements, and whenever the balance of the account is lower than US$60,000 equivalent. The government must ensure that amounts deposited in the Project Account are used exclusively for the project. 35

42 Financial monitoring; report: The project would submit the financial monitoring report (FMR) on a quarterly basis and within 45 days following the end of the quarter. A copy of the guidelines for borrowers dated November 30, 2002 was given to DAAF. The content of the FMR would be finalized when the FMA would be recruited. 36

43 Task 1- Finalize and adopt the administrative and accounting acceptable for IDA 1.1 Update the Manual based on Bank Financial Management Action Plan Person in Charge Due Date Before effectiveness Project May 15,2005 I comments on the draft. I teaddaaf I I 1.2 Review the manual updated 1.3 Completion of final version of Manual FMS Bank May 15,2005 Project May 31, IDA no objection on the whole process 2.8 Contract with the firm selected IDA June 20th, 2005 Project July 15th,

44 Annex 8: Procurement GUINEA: HEALTH SECTOR SUPPORT PROJECT A. General Procurement for the proposed project would be carried out in accordance with the World Bank s Guidelines: Procurement Under IBRD Loans and IDA Credits dated May 2004; and Guidelines: Selection and Employment of Consultants by World Bank Borrowers dated May 2004, and the provisions stipulated in the Legal Agreement. The general description of various items under different expenditure category are described below. For each contract to be financed by the Credit, the different procurement methods or consultant selection methods, the need for prequalification, estimated costs, prior review requirements, and time frame are agreed between the Borrower and the Bank project team in the Procurement Plan. The Procurement Plan would be updated at least annually or as required to reflect the actual project implementation needs and improvements in institutional capacity. In July 1996, the Govemment of Guinea took the political decision to launch a reform program to improve the transparency and efficiency of Guinea public procurement. The Bank responded to the Government s request for financial and technical assistance, by committing funds from the SAC I11 PPF, and then through an IDF grant in the amount of US$420,000 approved in March 1997 to support the implementation of Phase 1 of the reform. Phase 1 facilitated (i) the enactment of a revised Govemment Procurement Code; (ii) the publication of documents defining its terms of application; along with standard bidding documents and general conditions of contracts; and also (iii) the introduction of a computerized tracking system for procurement programs. Following the 2002 CPAR update the Government requested the Bank support to execute Phase 2 of the reform program which aims at fighting corruption; strengthening transparency and competition; increasing quality and efficiency, and establish a procurement legislative framework which complies with obligations deriving from national and international requirements. The Govemment started implementing activities under Phase 2, and IDA is considering committing IDF funds to support the Government in implementing the second Phase of the procurement reform agenda. Community Participation for the Procurement of Works (US$1.5 million): Works procured under this project would include the renovation of 75 health centers which have been identified in the 18 prefectures covered by the project. It is expected that these renovation works would be procured by CRDs. Procurement procedure at the CRD-level have been established in the Procurement Guide for Community Participation which was developed for the implementation of the Bank-financed PACV project and was approved by the Bank. These procedures are detailed in the Project Implementation Manual for this project. Procurement of Goods (US$5.92 million): Goods and equipment procured under this project would include : medical and other equipment, materials, vehicles, computers, drugs and other me dical consumables, and miscellaneous equipment for implementing agencies. The total value of goods is estimated at about US$5.92 millions equivalent for the project. The procurement would be done using Bank s SBD for all ICB and National SBD agreed with (or satisfactory to) the Bank. Contracts for Equipment, materials, vehicles, computers, fumiture and other equipment costing US$150,000 and more would be awarded on the basis of International Competitive Bidding (ICB), using World Bank Standard Bidding Documents for procurement of goods (published in January 1995, revised January and August 1996, September 1997, January 1999 and 38

45 May 2004). Contracts for office equipment, vehicles and materials locally available which are costing less than US$150,000 equivalent per contract but greater than US$50,000 would be procured through National Competitive Bidding (NCB) procedures acceptable to IDA. Small quantities of goods such as offices supplies, consumable materials and spare parts, which are normally available off-the shelf at competitive prices and which cannot be grouped into package of at least US$50,000 would be procured through prudent National Shopping in accordance with provisions of paragraph 3.5 of the Guidelines and the Bank s Guidance Procurement Note on Handing Procurement under Shopping Method (June 8,2000). Solicitations would be issued in writing to at least three reputable suppliers (preferably more) in order to receive at least three competitive quotations. Solicitations would give specifications, and if not immediately available, the delivery time. Written quotations would be opened at the same time for evaluation and records of award decisions would be kept for Bank supervision missions and audits. Goods which meet all the requirements for Direct Contracting may be procure in accordance with the provisions of paragraph 3.6 and 3.7 of the Guidelines, with IDA S prior reivew. Procurement from UN Agencies: Procurement of goods for components A and B of the project and pharmaceuticals and vaccines regardless of the cost may be procured directly from UNFPA, IAPSO, UNICEF or WHO in accordance with the provisions of paragraph 3.1 and 3.9 of the Guidelines. Selection of Consultants (US$4.96 million): Consultant Services financed by IDA would normally be selected through competition among qualified short-listed firms in which the selection would be based on Quality-and-Cost-based (QCBS) by evaluating the quality of the proposal before comparing the cost of the services to be provided. For audits of a standard nature, the least Cost Selection (LCS) would be the most appropriate method. The firm with the lowest price would be selected, provided its technical proposal received the minimum mark. Training and advisory services estimated to cost less than US$lOO,OOO would be contracted using Selection based on Consultant s Qualification (CQ). Services for small studies and seminars which can be delivery by Individual Consultants (IC) would be selected through comparisons of qualifications among those expressing interest in the assignment or through direct approach on the basis of work programs and terms of reference whenever possible in a competitive way from list of candidates drawn from a roster of individual consultants. Local community support service, such as technical assistance and training, may be procured through Single Source Selection (SSS), provided the contractor has demonstrated experience and comparative advantage to carry out the tasks. Short lists of consultants for services estimated to cost less than US$lOO,OOO equivalent per contract may be composed entirely of national consultants in accordance with the provisions of paragraph 2.7 of the Consultant Guidelines. However, if foreign firms have expressed interest, they would not be excluded from consideration. Operational Costs: Operational costs, such as utilities, printing, translation, office supplies, office space rental, building vehicle operation and maintenance would be purchased based on standard procedures defined in the Manual of Procedures. Prior Review The following contracts would be subject to the Bank s prior review: (a) each contract for goods, works and services (other than consultants services) estimated to cost the equivalent of US$150,000 or more procured on the basis of International Competitive Bidding; (b) the first 10 contracts for the rehabilitation of health centers procured through the Community Participation method; (c) each contract procured on the basis of Direct Contracting; (d) each contract for

46 Consultants Services to be provided by a firm estimated to cost the equivalent of US$lOO,OOO or more; (e) each contract for Consultants Services provided by an individual estimated to cost the equivalent of US$50,000 or more; and (0 all contracts procured on the basis of Single Source Selection. All other contracts shall be subject to Post Review. B. Assessment of the agency s capacity to implement procurement Procurement activities would be carried out by the Financial Directorate (DAAF) of Ministry of Health (MOH). A Fiduciary Management Agency (FMA) would be hired to help the DAAF in procurement. The manual of procedures would be prepared. It would serve as a practical guide describing procedures agreed upon in negotiations. It would include: (i) procedures for calling for bids, selecting consultants and awarding contracts; (ii) internal organization for supervision and control, including operational guidelines defining the role of The DAAF and the FMA and reporting requirements; and (iii) disbursement procedures. A Manual of procedures would be adopted before effectiveness. An assessment of the capacity of the Implementing Agency to implement procurement actions for the project has been carried out by Gnoleba Mathieu Meguhe on May The assessment reviewed the organizational structure for implementing the project. Most of the issues/ risks concerning the procurement component for implementation of the project have been identified and include: 9 weak capacity in procurement (deficiencies in the quality of bidding documents, inconsistencies in evaluation of bids) 9 Contract management is far from satisfactory (incomplete delivery of goods or works); 9 Delays in making payments to consultants, contractors, and suppliers for services rendered or goods delivered; 9 Poor record keeping and maintenance of procurement document. The corrective measures which have been agreed are: 9 A Fiduciary Management Agency (FMA) would be hired to help the DAAF in procurement and financial management for at least two years; P A procurement planning and contract management system would be installed; P Filing of procurement-related documents would be reorganized; 9 The DAAF staff would me trained. The overall project risk for procurement is Moderate. C. Procurement Plan During negotiations, the Borrower submitted a draft procurement plan covering 18 months of project implementation and provided assurances that standard bidding documents to be used under NCB procedures for goods would be submitted for IDA S approval. D. Frequency of Procurement Supervision In addition to the prior review supervision to be carried out from Bank offices, the capacity assessment of the Implementing Agency has recommended twice-a-year supervision missions to visit the field to carry out post review of procurement actions. 40

47 ATTACHMENT 1 DETAILS OF THE PROCUREMENT ARRANGEMENTS INVOLVING INTERNATIONAL COMPETITION. 1. Goods and non consulting services. (a) List of contract Packages which would be procured following ICB and Direct contracting: 2 Contract (Description) 3 4 (US$ ' 000) Method Domestic Review p-q Pmc!;e:;e bybank (Prior I Expected Bid- Opening Comments Emergency Obstetrics Care Equipment and goods (SOUC) Emergency Basci Obstetrics Equipment and Goods (SOUB) Complement to PPSG infrastructures Equipment Ambulances with radio Motos et bicycles VChicules =I= 1,141 I q=f 2 ICB 2 No No Prior Prior (b) ICB contracts estimated to cost above US$150,000 per contract and all Direct contracting would be subject to prior review by the Bank. 2. Consulting Services. (a) List of Consulting Assignments with short-list of intemational firms Ref. No. Description of Assignment Recruitment of an audit firm Recruitment of a Fiduciary Management Agency Estimated cost Selection Review Expected Comments Method by Bank Proposals (Prior I Submission Post) Date LCS Prior June 2004 QCBS Prior July

48 (b) Consultancy services estimated to cost above US$lOO,OOO per contract and Single Source selection of consultants (firms) for assignments estimated to cost above US$50,000 would be subject to prior review by the Bank. (c) Short lists composed entirely of national consultants: Short lists of consultants for services estimated to cost less than US$lOO,OOO equivalent per contract, may be composed entirely of national consultants in accordance with the provisions of paragraph 2.7 of the Consultant Guidelines. 42

49 Annex 9: Economic and Financial Analysis GUINEA: HEALTH SECTOR SUPPORT PROJECT This operation would improve the efficiency of the health system: Improving quality of care, re-allocation of resources to regions with larger disease burden from urban areas, implementing cost-effective basic essential package, focusing of effective solutions for communicable disease control, increasing immunization coverage, etc. can enhance the efficiency of the health systems in reducing the burden of disease. In view of severe budget limitations, increasing technical and allocative efficiencies are very important. Harnessing private expenditures: Private spending is a major source of financing for the health sector and in 2001, 83.5% of total health spending in Guinea was from private sources. The latest available data on the characteristics of private spending is from Data show that in both urban and rural areas, the majority of private spending is for home treatment. In urban areas, clinic visits are the next highest recipient of private spending followed by home visits and visits to dispensaries. In rural areas, after home treatment, home visits are the next highest recipient of private spending followed by pharmacies. It is interesting that private spending on hospital care in urban areas is zero as compared with 3.8% in rural areas. Placed in the context of the benefit incidence analysis, this may an indication that public spending is crowding out private spending on health care. From the available data, it is also clear the private spending on health care is largely targeted towards the private formal and informal sector and only in marginal amounts towards the public sector. In terms of regional breakdown of private spending, data from 2001 indicates that private spending is the highest in Conakry, the capital city (926.7 million GNF) as compared with very low amounts (almost zero) in Mamou, Boke and Faranah. The data clearly indicates that private spending in largely concentrated in urban areas. Almost 99% of private spending on health care is on an out-of-pocket (OOP) basis at point of service. Other sources such as private health insurance, public sector employer contributions consist of only 1% of total private health spending. Point of service payments are largely considered to be regressive and in addition there are concerns with the efficiency and quality of these private expenditures. This raises important policy implications in terms of developing health insurance mechanisms that can mobilize private spending for health care in a risk pooling context as well as the need for the government to regulate private health care providers to ensure value for money for consumers. In terms of health services provision, the private sector in Guinea comprises an informal sector where an estimated six to eight thousand traditional healers practice using traditional methods and medicines, and a formal sector, essentially operating in Conakry and in larger urban cities, comprised of doctors and dentists, nurses, pharmacists. The Government has recognized the importance of promoting the development of private sector. Yet government incentives and framework to increase both the formal and informal private sector s involvement in the provision of services are still lacking. In terms of services provision, the public private partnership is very limited. There is some collaboration and coordination of activities with some local and international NGOs operating in the health sector, such as., the Association Guinean de Bien-Etre Familiale (AGBEF), the Association for Voluntary Surgical Contraception (ASVC), MCdecins du Monde, Doctors Without Borders, and the Catholic church. 43

50 In terms of private sector financing of health services, the benefits of prepayment for services have been recognized but no such mechanism has been developed to date. The existing social security system has been covering a very limited number of individuals in Conakry. In 1991, cost sharing schemes were introduced to ensure demand-driven incentives, regular supply of essential drugs, and increased quality of care. User fees were pegged to be affordable for the population. A pricing structure was established with cross-subsidization between less essential services and more essential services. Essential preventive services such as immunization, supplementation with vitamin A, or treatment of diarrhea with ORT are now officially free. Children s treatment for essential ailments such as malaria or infections is offered at a very low cost. The Government regularly provides subsidies to health centers for drug purchases. Public-private collaboration in the financing of services has allowed cost recovery of approximately 20 percent of the total cost of the system. Aside from cost sharing, households also spend in the formal and informal private sector. Integrated household survey data reveal that households spend on average 7 percent of their income on health. This operation would address those issues by: 9 improving risk pooling through the health mutuals P ensuring that existing private resources are used to reach public health goals 9 the program approach would help the ministry to have a consolidated budget which can channel more donor money and avoid duplications 9 the program approach would help Government focus on results rather than the usual project implementation progress. This operation would improve the effectiveness of the health system: The programs and focus need to be fine tuned to the emerging epidemiology as Guinea makes rapid progress. For example, as child mortality reduces, the neonatal component of child mortality becomes important. To make further progress, there would be need to focus on causes for large neonatal deaths. ANC and institutional deliveries can help in further reducing the neonatal mortality. Drop outs between first dose of immunization and complete doses of immunization is very high. Similarly, there is drop between one visit and minimum four visits of ANC. Less continuity would lead to less effectiveness. Efforts like stronger outreach, improvements in quality of care, and increasing community participation can help in reducing the drop-outs and increase effectiveness. An analysis of the way the Five-Year Plan can contribute to the MDGs would be undertaken during appraisal. Such analysis would also help prioritize the most effective interventions. The mismatch between budget allocations and expenditures in health sector show that the execution part needs to be improved. Disproportionate expenditure on recurrent costs and less expenditure on operational and maintenance costs leads to lower effectiveness of the health infrastructure. Budget allocations need to be balanced so that effectiveness is highest. To achieve this balancing of budget it may be necessary to not open new health facilities till the budget can support the operational and maintenance costs of current infrastructure as well as proposed infi-astructure. During the first year of the project, an analysis of the recurrent costs implications of the health map would be undertaken to help the MOH minimize recurrent expenditures. Under the PPF the health map would be updated to include the private sector in order to harness this existing resource which, up to now, has never been taken into account. 44