PROJECT INFORMATION DOCUMENT (PID) CONCEPT STAGE. Health Service Delivery Project (HSDP) Region

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1 PROJECT INFORMATION DOCUMENT (PID) CONCEPT STAGE Project Name Health Service Delivery Project (HSDP) Region AFRICA Sector Health (100%) Project ID P Borrower(s) GOVERNMENT OF ANGOLA Implementing Agency Ministry of Health Angola Environment Category [ ] A [X] B [ ] C [ ] FI [ ] TBD (to be determined) Date PID Prepared June 10, 2008 Estimated Date of February 23, 2009 Appraisal Authorization Estimated Date of Board May 28, 2009 Approval 1. Key development issues and rationale for Bank involvement 1. Report No.: AB3951 Angola s health indicators are among the worst in the world. At 260 deaths per 1,000 live births, the child mortality rate is the second worst in the world after Sierra Leone (270), and, as shown on the chart, if the present trends continue, Angola has little chance of reaching that MDG. Maternal mortality, estimated at 1,750 per 100,000, is also among the highest in the world. An explanation for the poor performance of the sector is the prolonged war that severely damaged the country s infrastructure, with 65 percent of health facilities destroyed. A large proportion of health staff took refuge in Luanda where 70% of doctors, 30% of nurses, and 45% of other health staff have remained. As a result, the coverage for basic health services is low, and the majority of the population is not protected by basic and effective health services. Even though the government is currently rehabilitating the health network, a high percentage of facilities are still not functional, especially the bottom tier of the health network (health centers and health posts) that is the least functional, and yet this is the main vehicle to deliver primary health care to the population. Angola has only 8 doctors per 100,000 people, much lower than the average for African countries. The result is that 60 percent of the population does not have reasonable access to health care. People still have to walk more than one hour to reach a health facility. Also, the government relies too much on health service delivery in fixed facilities (hospitals and health centers), whereas experience from other countries shows that it should be complemented by outreach and community services that are highly cost-effective.

2 Yet Angola has a great opportunity to make a difference in health outcomes. First, since 2002, the country has been enjoying peace for the first time in more than 40 years. Second, Angola s economic outlook is promising. Angola s economy has been growing strongly at close to 20 percent per annum over the last three years. Economic growth is likely to continue with the output of crude oil forecast to reach 1.95 m barrels/day in 2008 and The government recognizes the important role of the health sector in economic growth. The budget for the health sector significantly increased over the last five years, and even doubled between 2005 and In 2006, the health budget was US$71 per capita, representing 3.4 percent of GDP. This spending, although high by Sub-Saharan standards, is not having the expected impact on health outcomes, principally because of the low coverage, and the poor targeting and quality of services. With donors support, the government has made commendable efforts to control the HIV/AIDS epidemic and has been successful so far, with prevalence remaining at 2.5 percent. It is also scaling up its malaria control efforts, notably through the distribution of bed nets in all provinces and the replacement of chloroquine, to which the malaria parasites have developed resistance, by ACT. This will contribute to child and maternal mortality reduction. The government plans to significantly scale up the coverage of basic health services. Relevance to CAS Objectives. The proposed project is directly in line with the Bank s Interim Strategy Note for Proposed objective(s) The first objective of the project is to improve the population s access to health services in four selected provinces by: (i) strengthening community-based service delivery; (ii) scaling up outreach services; and (iii) improving and expanding facility-based services. The proposed project would bring Angola closer to the MDGs by helping to reduce child mortality (goal 4); and maternal mortality (goal 5). It would help introduce an effective health service delivery model that the government could implement throughout the country, thus increasing the effectiveness of health spending. The second objective is to contribute to the control of malaria. The third is to strengthen the institutional capacity of the Ministry of Health (MOH). 3. Preliminary description The project would have four components: (i) improving service delivery in four selected provinces (Benguela, Cabinda, Namibe, and part of Luanda (US$15.0 million); (ii) pilot testing of conditional cash transfers (CCTs) to increase institutional deliveries (US$2.0 million); (iii) boosting of national malaria control (US$4.0 million); and (iv) strengthening the capacity of the MOH (US$1.0 million). It would have a life of five years. Selection criteria for the provinces are: (i) the country s epidemiological profile; (ii) the priorities of the central government; (iii) the political commitment of the provinces: (iv) the presence of UNICEF and other donors; and (v) the ease of access. The selection of the proposed four provinces needs to be reviewed with the government. The project would support an integrated mode of health service delivery consisting of: (i) health facilities providing a complete package of basic health care services; (ii) outreach teams that

3 would start from health facilities and visit districts according to a regular schedule, bringing preventive and simple curative services to the population, and (iii) community health workers, supervised by outreach teams, who would promote healthy behavior in the population, help recognize early signs of illness, and provide some basic drugs. Component 1 - Improvement in service delivery (US$12.0 million). There would be two main areas of intervention: (i) the improvement of skills and knowledge of district health staff in management and planning, including organization and supervision of outreach and communityoriented activities; and (ii) the improvement of the quality of service provision, particularly in the areas of maternal and child health, with the boosting of integrated management of childhood illnesses (IMCI) and safe motherhood skills. Maternal health would be improved through the early detection and management of pregnancy complications, and the amelioration of emergency obstetric care. Component 2 Pilot testing of conditional cash transfer to increase institutional deliveries (US$2.0 million). One of the most effective means of preventing maternal mortality is to encourage mothers to use skilled birth attendants for delivery, and, even better, deliver their baby in hospitals where they can have access to 24-hour emergency obstetric care. The project would pilot cash subsidies to pregnant women to deliver in a health facility This would consist in: (i) cash incentives; and (ii) transport subsidies. The project would also test supply subsidies to hospitals, allowing them to increase their capacity for institutional delivery. These conditional cash transfers would be tested in 1-2 districts of a selected province. Results would be used by the government to decide on a possible geographical expansion of the subsidy using government funds. In February 2008, the Minister of Health expressed strong interest in CCT. This component builds upon the success of conditional cash transfer (CCT) programs around the world, some of the most notable ones being the Oportunidades experience in Mexico and the Bolsa Escola program in Brazil. These programs are relatively new, but evaluations show that conditional cash transfer programs are an effective means for promoting human capital accumulation among poor households. There is clear evidence of success in increasing enrollment rates, improving preventive health care, and raising household consumption. Component 3 - Boosting of national malaria control program (US$ 3.0 million). The project would support malaria control at the central level, and nationwide to fill gaps in financing from the government and other donors, with IDA support primarily targeted to the health system aspects of malaria control such as improving program management, supply chain strengthening, and monitoring and evaluation capacity at the central and provincial levels. Component 4 Strengthening the capacity of the Ministry of Health (US$1.0 million). This component would support the preparation of: (i) a Health Infrastructure Investment Plan; (ii) a Medium-Term Human Resources Development Plan; and (iii) a Medium-Term Expenditure Framework (MTEF). Implementation arrangements. The project would be managed by a Project Coordinating Unit (PCU) within the MOH, working in close collaboration with the central MOH programs and the

4 provinces. The PCU Director would be the Director of Planning of the MOH, assisted by a Deputy Coordinator, who would be in charge of the day-to-day management of the project, and coordination with the central MOH staff and the provinces. The responsibility for each of the project s four components would be attributed to a component coordinator. The rest of the team would include an M&E Specialist, a Financial Management Specialist, and a Procurement Specialist. This structure, requested by the MOH, is very similar to that of the HAMSET Project that has been working well. In fact, by the time the proposed Angola HSDP project would become effective, HAMSET would be in its last year of implementation, and conceivably its staff could be contracted for the HSDP. At the provincial level, the main person responsible would be the Provincial Health Director. He/she would be supported by additional staff for day-to-day project implementation and coordination with the PCU. Project alternatives. Why not HAMSET II? Through HAMSET, the Bank has been the first external financier to help the government control HIV/AIDS, TB, and malaria. This has led the way to further funding from the Global Fund and the US President s Malaria Initiative, as well as increased financing for HIV/AIDS control from the government itself. On the other hand, maternal and child health indicators are appalling, justifying the strategic decision to give priority to investing in the improvement of these health outcomes. No project alternative. The no project alternative is not desirable because child and maternal mortality are very high in Angola, and malaria devastating. Without an operation that introduces an integrated service delivery model, Angola s chances of reaching the MDGs in 2015 would be slim. Pooled financing model of SWAp The full SWAp model was considered as a possible option. However, in the Angolan context, the transaction costs associated with such a model would be onerous and inefficient at this time, especially that there is not a large number of donors in the health sector. Lending instrument. In this case, we propose to use a Sector Investment Loan (SIL). This is because the SIL is a flexible lending instrument appropriate for a broad range of projects. SILs help to ensure the technical, financial, economic, environmental, and institutional viability of a specific investment. They can also support policy reform. 4. Safeguard policies that might apply [Guideline: Refer to section 5 of the PCN. Which safeguard policies might apply to the project and in what ways? What actions might be needed during project preparation to assess safeguard issues and prepare to mitigate them?] 5. Tentative financing Source: ($m.)

5 BORROWER/RECIPIENT 0 International Development Association (IDA) 20 Total Contact point Contact: Jean J. De St Antoine Title: Lead Operations Officer Tel: (202) Fax: Jdestantoine@worldbank.org